One of the most important conversations I had was with a medical professional who specialized in Breast Cancer. This after having been evaluated by the Nurse Practitioner I see every year for my annual exam, who felt like I had breast "lumps" that should be more closely scrutinized. The diagnoses by the Breast Cancer MD., was that all was normal, and what I should be looking for to alert me to anything out of the norm was this... "A cancerous lump will be ROCK HARD." In all my years in going to the Dr. and being told to perform self examinations, I had NEVER heard that description. Why is that? I was just told to feel for lumps, not ROCK HARD lumps. C'mon, that's very different. So, for 35 years, I have been performing self exams every month, freaking out about the lumps, which are benign fibroids. Why is it the medical community hasn't seen fit to dispense with this valuable information??? Oh, that's right, they want to keep us uninformed so we'll run to the Dr. at any given moment running up their tabs.
11
What is or is not a cancer, in the future will be based on genetic testing. Looking at cells with a microscope is hugely variable. Cancer is a genetic mutation and it should diagnosed and treated based on this.
1
It's time that the non-pathologist world understood what pathologists have known for decades - that the diagnosis of borderline breast lesions is both difficult and non-reproducible. Yes, it's possible to find an "expert" to render an opinion, but there is nothing remotely resembling unanimity even among those experts. And, as pointed out in the JAMA article, "... there is no evidence that the classifications of the consensus panel members are more accurate with respect to predicting clinical outcomes than the classifications of the participating pathologists". And I cannot help but note that the among the three "experts" in the study, about 20% of the "atypical" cases were "misclassified". Among the Boston academic centers, there is no uniformity of diagnosis in such lesions, and even within these departments, different pathologists use different criteria and thresholds for diagnosis of DCIS.
20
The explosion of "cancer" diagnoses occurred with the new high resolution mammograms; now "abnormalities" have increased dramatically.
Other fields of medicine require board certification such as plastic surgery. You get your 4 year MD, then 3 years of general surgery, then up to 5 extra years SPECIFICALLY doing plastic surgery in a plastic surgery fellowship. Not so with breast cancer "specialists." There are NO fellowships for breast surgeons! After three years of general surgery, some of these generalists begin doing a lot of breast surgeries and so become known as "breast specialists" WITHOUT a specific fellowship revolving around radiation, chemo and cancer surgery involving the breast!
As an MD I find it incomprehensible that so many surgeries are being done without any specific board certification! We used to see the same thing with plastic surgery. General surgeons would call themselves "cosmetic surgeons" after they did a lot of plastic work..breast augmentations, facelifts WITHOUT going through a specialized fellowship. Only within the last few decades has plastic surgery been established as a specific board certification.
It's obvious to me that we have to pause, take a breath, and see where we are!
First we need Board Certification for Breast Surgery specialists. Older general surgeons may be grandfathered in, but these fellowships MUST be established at major research and university centers. Only then can we look at pathologists, chemo and radiation!
Other fields of medicine require board certification such as plastic surgery. You get your 4 year MD, then 3 years of general surgery, then up to 5 extra years SPECIFICALLY doing plastic surgery in a plastic surgery fellowship. Not so with breast cancer "specialists." There are NO fellowships for breast surgeons! After three years of general surgery, some of these generalists begin doing a lot of breast surgeries and so become known as "breast specialists" WITHOUT a specific fellowship revolving around radiation, chemo and cancer surgery involving the breast!
As an MD I find it incomprehensible that so many surgeries are being done without any specific board certification! We used to see the same thing with plastic surgery. General surgeons would call themselves "cosmetic surgeons" after they did a lot of plastic work..breast augmentations, facelifts WITHOUT going through a specialized fellowship. Only within the last few decades has plastic surgery been established as a specific board certification.
It's obvious to me that we have to pause, take a breath, and see where we are!
First we need Board Certification for Breast Surgery specialists. Older general surgeons may be grandfathered in, but these fellowships MUST be established at major research and university centers. Only then can we look at pathologists, chemo and radiation!
22
It's pretty hard to get a "second opinion". Doctors generally don't contradict each other -- not wanting to find themselves in the same position down the road. So you go for a second opinion and you get the same opinion. Besides giving a different opinion opens you up to scrutiny too. I don't even get it -- do patients just accept the second opinion as the final word?
14
As a family doctor who refers out I have found the opposite. I have gotten three different diagnoses from three different pathologists.
Most doctors WILL contradict each other--it's that ego coming to the surface. No MD wants to be "out done."
There is an old saw that ten orthopedic surgeons will treat the EXACT same injury ten different ways. It depends on experience, where the doctor is employed--e.g. small private hospital vs major university research area.
This is why we need board certified breast surgeons--which don't exist right now! General surgeons are depending on pathologists doing their diagnosing for them. Once we start getting board certified breast surgeons who work ONLY with breast cancer all day, every day, will we start getting better diagnosis and better treatment modalities.
Breast cancer treatment is incredibly diverse. Instead of one oncology surgeon managing the patient we have a pathologist, a radiology doctor who "decides" he will specialize in breast cancer, a medical oncologist who "decides" to do breast cancer, and a general surgeon who "decides" to be a "breast specialist."
There has been SO much money thrown at breast cancer (An entire month of "pink" awareness campaigns) that many providers are jumping on the wagon to get those dollars.
University research hospitals and centers such as the Mayo or Cleveland Clinics MUST take the lead and establish breast specialties...then pull in all these different doctors to work together!!
Most doctors WILL contradict each other--it's that ego coming to the surface. No MD wants to be "out done."
There is an old saw that ten orthopedic surgeons will treat the EXACT same injury ten different ways. It depends on experience, where the doctor is employed--e.g. small private hospital vs major university research area.
This is why we need board certified breast surgeons--which don't exist right now! General surgeons are depending on pathologists doing their diagnosing for them. Once we start getting board certified breast surgeons who work ONLY with breast cancer all day, every day, will we start getting better diagnosis and better treatment modalities.
Breast cancer treatment is incredibly diverse. Instead of one oncology surgeon managing the patient we have a pathologist, a radiology doctor who "decides" he will specialize in breast cancer, a medical oncologist who "decides" to do breast cancer, and a general surgeon who "decides" to be a "breast specialist."
There has been SO much money thrown at breast cancer (An entire month of "pink" awareness campaigns) that many providers are jumping on the wagon to get those dollars.
University research hospitals and centers such as the Mayo or Cleveland Clinics MUST take the lead and establish breast specialties...then pull in all these different doctors to work together!!
16
The JAMA report and this news article fail to mention the large clinical literature on inter and intra observer variability in the interpretation of diagnostic tests. For many tests -- such as chest x-rays -- there is a 25-30% disagreement rate among experts and even for the same expert reading the same test many times. This kind of observer variability is not unique to breast biopsy interpretation and should be reported so that readers and medical consumers can appreciate that variability occurs even among the most expert observers for a wide variety of diagnostic tests that involve human interpretation. Getting "other" or "second" opinions might not solve the problem. The "less is more" crowd should not use this report to deny women breast biopsies for "scientific" reasons. They can do so to balance the budget.
7
After 40 years in medicine I can tell you that medicine is much more an "art" rather than a science.
25-30% differences isn't too bad actually! Every medical school is different, every teaching professor is different. There are only so many doctors who will give up a very lucrative career to teach! Then medical knowledge changes so very quickly! I am 12 months behind on podcasts--god only knows what I'm missing out here!
Medical doctors are THE most conservative "scientists" (artists?) I know. They may learn one thing in medical school or a residency 35 years ago...and they won't change no matter what information is out there.
That became obvious with the recent kerfuffle over vaccinations vs anti-vaxers. There is a saying: "Neither be the first nor the last." Try not to be the first to try a new procedure, new medication, new treatment---At the same time don't be the last to be doing something either. One really does need to change with the times.
And here is where the "art" comes in. After so many years of practice a doctor may find that his patients will NEVER finish two weeks of antibiotics and therefore reduces it to one week..even though every journal will insist on at least two weeks.
A Ford mechanic knows that every 1985 Ford 150 uses a specific part--he knows--it's in the Chilton Auto Repair manual for 1985 Ford 150s! But every human born in 1985 doesn't come with ANY manual!
It really is an art...and the best doctors are Rembrandts..or Picassos!
25-30% differences isn't too bad actually! Every medical school is different, every teaching professor is different. There are only so many doctors who will give up a very lucrative career to teach! Then medical knowledge changes so very quickly! I am 12 months behind on podcasts--god only knows what I'm missing out here!
Medical doctors are THE most conservative "scientists" (artists?) I know. They may learn one thing in medical school or a residency 35 years ago...and they won't change no matter what information is out there.
That became obvious with the recent kerfuffle over vaccinations vs anti-vaxers. There is a saying: "Neither be the first nor the last." Try not to be the first to try a new procedure, new medication, new treatment---At the same time don't be the last to be doing something either. One really does need to change with the times.
And here is where the "art" comes in. After so many years of practice a doctor may find that his patients will NEVER finish two weeks of antibiotics and therefore reduces it to one week..even though every journal will insist on at least two weeks.
A Ford mechanic knows that every 1985 Ford 150 uses a specific part--he knows--it's in the Chilton Auto Repair manual for 1985 Ford 150s! But every human born in 1985 doesn't come with ANY manual!
It really is an art...and the best doctors are Rembrandts..or Picassos!
5
I am a pathologist at a large hospital in CA with over 30 years experience looking at a large number of breast bx cases. I would like to make two points about the referred study:
1) the impression given in the article is that the 3 experts on the panel were in complete monolithic agreement regarding the diagnoses. This is not the case. If you go to the article and look at the data, (http://jama.jamanetwork.com/article.aspx?articleid=2203798) you will find that, for example, of 216 cases that were by consensus regarded as benign, that the expert panel had initially called 15 of those atypical, 3 DCIS, and 1 invasive. Of 216 cases that were by consensus called atypical, 18 had initially been called benign and 25 DCIS. In other words the hard cases are hard for everyone.
2) So how did the expert panel iron out these differences in their initial opinions? Pretty much in the same way that "real" pathologists do- they got together and shared the cases and hashed it out and came to an agreement-- all activities that were specifically forbade the study pathologists. The JAMA article states that "Four full-day in-person meetings were held following the panel members’ independent reviews to establish a consensus reference diagnosis..." To look at a single slide in isolation is a highly contrived situation and is not what we do. We show it around, we cut extra levels, we may do some extra stains and then, if there is still a problem, we send it out.
1) the impression given in the article is that the 3 experts on the panel were in complete monolithic agreement regarding the diagnoses. This is not the case. If you go to the article and look at the data, (http://jama.jamanetwork.com/article.aspx?articleid=2203798) you will find that, for example, of 216 cases that were by consensus regarded as benign, that the expert panel had initially called 15 of those atypical, 3 DCIS, and 1 invasive. Of 216 cases that were by consensus called atypical, 18 had initially been called benign and 25 DCIS. In other words the hard cases are hard for everyone.
2) So how did the expert panel iron out these differences in their initial opinions? Pretty much in the same way that "real" pathologists do- they got together and shared the cases and hashed it out and came to an agreement-- all activities that were specifically forbade the study pathologists. The JAMA article states that "Four full-day in-person meetings were held following the panel members’ independent reviews to establish a consensus reference diagnosis..." To look at a single slide in isolation is a highly contrived situation and is not what we do. We show it around, we cut extra levels, we may do some extra stains and then, if there is still a problem, we send it out.
46
All studies leave room for doubt.
It is impossible to predict such outcomes with a high degree of accuracy.
Individual choice is somewhat important, but luck is still a quintessential ingredient to any long and healthy life.
It is impossible to predict such outcomes with a high degree of accuracy.
Individual choice is somewhat important, but luck is still a quintessential ingredient to any long and healthy life.
3
As a pathologist practicing for over 25 years, I have seen screening recommendations evolve and mammography become more sensitive. This study represents more advancement of knowledge about diagnostic accuracy and the interobserver variability that occurs in all of medicine. This is how we improve and develop best practices. My best advice to the bewildered patient is to make sure that your breast cancer, invasive or carcinoma-in-situ, is discussed at a multidisciplinary conference that includes a pathologist, radiologist, general surgeon, plastic surgeon, medical oncologist and radiation oncologist, where a consensus regarding treatment is reached, before proceeding with any therapy (surgery, chemo, radiation or reconstruction).
19
A multi-disciplinary conference would be great. But it doesn't happen in the real world. I just went through breast surgery and found communication sorely lacking.
In fact, the oncologist I initially saw got irritated with me for asking too many questions. And he didn't even want to see me until AFTER the surgery was done.
In fact, the oncologist I initially saw got irritated with me for asking too many questions. And he didn't even want to see me until AFTER the surgery was done.
7
Also, I found out later I could have had a full mastectomy and recontruction, and then wouldn't have needed radiation. No one ever even mentioned that option.
I hate radiation. It damages the skin. But even moreso, i am very afraid of the long-term effects. The radiation itself can cause cancer and orher problems!
I hate radiation. It damages the skin. But even moreso, i am very afraid of the long-term effects. The radiation itself can cause cancer and orher problems!
9
The basic math of any screening test can lead to many false positives if it is used on large numbers of low-risk people. Statisticians talk about something called Bayes' Rule, but you don't really need a fancy equation, you can just do two multiplications. Multiply the number of people being screened who do not have the condition in question times the false positive rate of the test to get the number of false positives. Just multiply the number of people being screened who do have the condition in question times the true positive rate of the test to get the number of true positives.
Unless you have either a very accurate test or you only screen people with a high probability of having the condition in question, there will be far more false positives than true positives. Now consider the consequences of a false positive.
Unless you have either a very accurate test or you only screen people with a high probability of having the condition in question, there will be far more false positives than true positives. Now consider the consequences of a false positive.
9
There is greater concern over the false negative.
3
As a breast surgical oncologist, I will point out that there is another crucial piece of information which has not yet been mentioned. The vast majority of breast biopsies are benign, roughly 80%, and the pathologists in this study were quite accurate at diagnosing purely benign samples. They were also remarkably accurate at diagnosing invasive cancer.
However, this study drastically oversampled the middle diagnoses of atypical cells and DCIS. By including such a huge number of these more uncertain diagnoses, the rate of "inaccuracy" of pathologic diagnosis will be greatly inflated. The study magnifies the real world rate of inaccurate diagnoses, which, as mentioned previously in these comments, will always have uncertainty.
However, this study drastically oversampled the middle diagnoses of atypical cells and DCIS. By including such a huge number of these more uncertain diagnoses, the rate of "inaccuracy" of pathologic diagnosis will be greatly inflated. The study magnifies the real world rate of inaccurate diagnoses, which, as mentioned previously in these comments, will always have uncertainty.
23
As a stage one breast cancer survivor (Massive DCIS, ILC) who underwent a bilateral mastectomy, I am shocked any wonan would question my choice. I didn't suffer 5 surgeries and painful reconstruction in order to have perky breasts in old age. I just wanted to live to old age.
14
But you could have lived to an old age without reconstruction, so what was the purpose in that?
2
I have had calcification show up in one place in my right breast. It has been there for as long as I've been having exams. I've been told my breasts are lumpy...though the don't feel that way to me. It has never been suggested that I have a biopsy, which I understand are incredibly painful...so thank God for that. I have had two close friends die from cancer, apparently spread from breast cancer which was treated years before. I don't want to die from cancer..(I've had surgery for colon cancer)..but, I'm so tired of the constant harping on this subject. And, now, something new for women to worry about?
3
Carole, there are many different types of breast biopsies. I myself have experienced three of them, two recently. Local anesthetic makes the procedures themselves painless. Afterwards, there is certainly some soreness and discomfort, but I wouldn't describe the feeling as incredibly painful--and I'm a real coward when it comes to pain. I went directly to work after undergoing a stereotactic core biopsy; the only real discomfort came from wearing a cold-pack tucked into my bra on a snowy day.
I hope you won't ever need a biopsy, but if you do, please don't decline to have one for fear of pain.
I hope you won't ever need a biopsy, but if you do, please don't decline to have one for fear of pain.
16
This article reflects the general ignorance of the population and of many physicians themselves in regards to pathological assessment of tissue samples. Pathological examination is not "mathematically" accurate, as in the rest of medicine, its part science and part art. Interpretation covers a spectrum with a great majority of cases where everyone can a agree but there is always a gray area where even so called experts cannot find consensus. One of those is the diagnosis of so called atypical ductal hyperplasia which has gone through many permutations across the decades. In general it encompasses abnormalities which are "not quite" DCIS. Even among DCIS there is still a smaller area of subjectiveness. BTW DCIS is not cancer given that cancer is a tumor that has the ability to metastasize which by definition DCIS does not. People tend to forget that a biopsy is like trying to look at the world through a straw, the fact that you have DCIS in one area of the breast does not rule out that you have undetected invasive cancer elsewhere in the same breast. Finally this study was conducted under artificial conditions, in most practices breast biopsies are examined by 2 pathologists, a first reader and a reviewer making the diagnosis of breast lesion a consensus one.
If you think there is a gray area on breast biopsies you should write an article on melanoma where the gray area is immensely larger.
If you think there is a gray area on breast biopsies you should write an article on melanoma where the gray area is immensely larger.
10
Also Pathologists don't look at just one slide/section as they did for each "patient" in this study. The article places too much emphasis on the biopsy procedure when the study they are reporting on was all about concordance of diagnosis among pathologists... but as usual truth suffers when the goal is to sell papers more than inform the public.
1
Despite decades of research that has characterized subcellular molecular mechanisms, cell biology remains rather mysterious on the whole cell level, reflecting the essential principle in living systems that the whole (cell) is more than the sum of its parts (molecules and individual mechanisms); hence the reasons for cellular appearance changes are likely myriad and are as yet unexplainable in their totality. Cellular responses to local inflammation minor physical trauma, and many other factors might produce cells that look abnormal but are merely engaged in acute restructuring (as are all cells, all the time). This could be yet another example of clinical medicine groping for answers in the face of the immense complexity of subcellular processes.
8
As an experienced practicing Pathologist, I find the Times presentation of the findings misleading. The design of the study does not emulate the way a local pathologist would address a challenging breast biopsy, with additional stains, additional submission of tissue, and both opinions from local colleagues and from extradepartmental experts available as tools. This type of study, of which there are many, is useful at a professional level but in this case is being badly applied. The comments to the article illustrate what an emotionally laden topic this is. A second opinion is not a bad thing in select cases, but we live in an environment in which this will be inappropriately mandated universally.
10
12 years ago I had a mammogram that revealed micro-calcifications. A subsequent stereotactic biopsy found DCIS. Since it was extensive in the duct I opted for a mastectomy. The final pathology revealed that the DCIS had, in fact, started to break out of the ducts. Since the biopsy only drew samples it did not reveal the spot where the cancer had become microinvasive, so it was the DCIS diagnosis that served as the catalyst for effective treatment. For me, making the choice I did based on the DCIS (which was the comedo - more aggressive - kind) was a good one. I had reconstruction and have not regretted my choice for a moment. My goal was to watch my daughter grow up and I've been lucky enough to have that privilege.
I was treated in an San Francisco hospital and trusted my doctors, but for those who have any doubt, certainly a second opinion is a good choice. That holds true throughout the process for those who require adjuvant therapy as well. I was lucky and only needed surgery to treat my disease.
I was treated in an San Francisco hospital and trusted my doctors, but for those who have any doubt, certainly a second opinion is a good choice. That holds true throughout the process for those who require adjuvant therapy as well. I was lucky and only needed surgery to treat my disease.
10
I had large areas of DCIS which masked invasive lobular cancer and also had atypical cells in other breast. Got double "angelique Jolie special," and was able to relax and regain my life. The amount of DCIS should be considered. I had too much for a wait & watch attitude.,
4
Patients need to understand that the radiologist is performing a SAMPLING procedure. Furthermore, the pathologist is performing a SAMPLING procedure on the samples themselves. The assumption is that the sample represents the whole picture, but as with all assumptions, they are just that. And they can be incorrect. But they are unavoidable.
Fundamentally, patients need to understand that these are TESTS and physicians are using their best judgment in converting pretest probabilities into post-test probabilities. An understanding of Bayes' theorem would be helpful for anyone contemplating medical care.
http://en.m.wikipedia.org/wiki/Bayes'_theorem
Fundamentally, patients need to understand that these are TESTS and physicians are using their best judgment in converting pretest probabilities into post-test probabilities. An understanding of Bayes' theorem would be helpful for anyone contemplating medical care.
http://en.m.wikipedia.org/wiki/Bayes'_theorem
8
Nothing is all certain. The quest for certainty can get out of hand. Perhaps it is better to live life to the fullest while you can. So when one's death is ahead of science, one doesn't have any regrets
4
An 84 year old woman I know was diagnosed with breast cancer recently. The reason I am posting this is that she discovered it herself by looking in the mirror. Medicare discontinued giving her mammograms because of her age.
6
I think you should check on the Medicare claim...the woman probably has some kind of insurance other than Medicare.
2
She said that their recommendations are once every 5 years for mammograms, I guess over 80. And she does have supplemental insurance.
Another woman in my circle died from colon cancer. Her mother had also died from that. She was also in her mid 80's and had gone almost 5 years with testing, again they said it was not standard policy to test at her age.
Another woman in my circle died from colon cancer. Her mother had also died from that. She was also in her mid 80's and had gone almost 5 years with testing, again they said it was not standard policy to test at her age.
2
Any word on how often the *experts* agreed with one another? "Atypia" is, by definition, in the gray zone and is a notoriously difficult diagnosis to make for any pathologist. Other studies have shown a high degree of incongruent diagnoses for atypia - among experts. Instead of only focusing on the differences between community pathologists (particularly since they weren't allowed to practice as they normally would in this study) and experts, let's also compare experts to experts.
2
Pardon my ignorance, but I have believed that multiple reviews of a biopsy is considered a part of the "standard of care".
Steve Rinsler, MD
Steve Rinsler, MD
10
There is a new method to obtain the data needed from a biopsy. A blood sample can be used to produce the necessary information. A recent study at Columbia U. addressed this and made strong recommendations as to the accuracy of this new method to replace a biopsy. It could be a very helpful advancement.
3
Ehhhhhhhh, NO! More simplistic newspaper misguidance. Not having circulating tumor cells by no means signifies you don't have a malignant tumor. Just another tool for risk stratification, at best.
3
Follow a vegan diet to reduce your risk of reproductive cancers (breast, ovarian, prostate) as well as your risk of other cancers.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048091/
The same diet that has been shown to reverse heart disease and type 2 diabetes. Oh, and it's the best thing in the world for, well, the world--and obviously for the animals. If we would put a fraction of the resources we funnel into medical solutions, into public health measures to promote a vegan diet and to subsidize fruits and vegetables (the way we now subsidize meat and milk)--there would be fewer breast cancer cases. But it's tough. As my husband always says, "No one gets credit for bad things that don't happen." As a society we seem more interested in the dramatic cure than in prevention. But I think most women would rather protect themselves from breast cancer than cure themselves after the fact.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048091/
The same diet that has been shown to reverse heart disease and type 2 diabetes. Oh, and it's the best thing in the world for, well, the world--and obviously for the animals. If we would put a fraction of the resources we funnel into medical solutions, into public health measures to promote a vegan diet and to subsidize fruits and vegetables (the way we now subsidize meat and milk)--there would be fewer breast cancer cases. But it's tough. As my husband always says, "No one gets credit for bad things that don't happen." As a society we seem more interested in the dramatic cure than in prevention. But I think most women would rather protect themselves from breast cancer than cure themselves after the fact.
6
Ehhhhhh, another old wives tale. Though we may wish that we could fix cancer or any other disease by simply eating more vegetables, it doesn't have a major effect on cancer rates for most cancers. Avoiding known carcinogens as those present in cigarette smoke and other does in fact help. The unfortunate fact is that we are constantly bombarded with so called carcinogens, many of which cant be avoided since they are part of nature, the one we all share being age and inborn genetic susceptibility. In fact most cancers are simply a result of getting dealt a less than robust genetic makeup or simply getting the short end of the straw.
15
I was a vegetarian for years -- I still got breast cancer. I don't smoke and I exercise regularly. Most people who get cancer are NOT in the "high risk" category. Oh, and I know a woman who was diagnosed the same time I was. She thought her diet could cure her. She's dead now.
11
Absolutely agree, but, eating more vegetables has lots of _other_ health and ecological advantages. So feel free to eat up, drveggie, but don't expect to cure a cancer.
You may be wondering about the constant bombardment of carcinogens that ED mentions. Some are: radon gas, radioisotopes in food, terrestrial sources, and galactic cosmic rays. https://en.wikipedia.org/wiki/Environmental_radioactivity
These are just a fact of life on Earth that we cannot escape. But, pass me the carrots, please.
You may be wondering about the constant bombardment of carcinogens that ED mentions. Some are: radon gas, radioisotopes in food, terrestrial sources, and galactic cosmic rays. https://en.wikipedia.org/wiki/Environmental_radioactivity
These are just a fact of life on Earth that we cannot escape. But, pass me the carrots, please.
1
I think most American patients view the work-up, expense and anxiety to run down a false positive result as being thorough and just an inconvenience.
3
There seems an inverse relationship between use of diagnoses and surgery and the lifestyle factors such as diet and exercise, the latter has been pathetically degraded into prescription rather than an innate desire of the body to move, turn, jump and run. The International agency for cancer research and many other national organizations have recommended physical activity to reduce 20-40 percent reduction in cancer. The question that seldom surfaces is: Are we going about addressing the bc problem with all available tools at hand, starting with the most easily and freely available? Until then we will be losing our fight because we would have been hijacked by our fears and misplaced or misguided hopes. As NEJM article of June 3, 2013 tells us: "... screening is having, at best only a small effect on the rate of death from breast cancer."
8
Health insurance usually does not cover second opinions. So how are the vast majority of people supposed to get their biopsy results clarified if they're not wealthy? I feel so sad when I read articles like this that clarify best practices, because most of the time this will never happen in the reality of actual medical care.
28
Well, a person with an I Phone, a car, color TV, Internet access, and a mani and a pedi every week can cut back on non essentials and pay for a second opinion. You can negotiate the price in advance for cash which is often considerably less because the doctor's office does not have to waste precious hours with insurance companies and insurance forms. Also sometimes the public health system will give assistance. You can also ask you health professional for a referral to another colleague and ask him / her to explain your financial circumstances and negotiate a better price. Americans take out loans for vacations, newer cars, sending children to expensive schools, maybe they should consider using the money for a second opinion instead. Years ago people used to pay for their own health care and it was a lot cheaper. patients negotiated the fees or they comparison shopped. This is why the American health system is so expensive, the free market has been taken out of the system.
3
Now health care is ruled by Big Insurance.
1
Atypical breast ductal lesions is arguably the most controversial area of diagnostic surgical pathology. Showing these cases around is a firm standard in actual practice that was apparently omitted from the study.
I contend that it would be impossible to ever prove that experts reading of atypical breast lesions makes an endpoint difference. Because, for one the experts cannot agree amongst themselves, and in fact have been fighting with each other on how to define entities, second the majority of those lesions are not associated with current or future high grade cancer, making it even harder to measure the effect (they will typically use proxies instead of measuring actual endpoints).
I contend that it would be impossible to ever prove that experts reading of atypical breast lesions makes an endpoint difference. Because, for one the experts cannot agree amongst themselves, and in fact have been fighting with each other on how to define entities, second the majority of those lesions are not associated with current or future high grade cancer, making it even harder to measure the effect (they will typically use proxies instead of measuring actual endpoints).
14
So great - basically what this article tells me is that the radiation "therapy" (and I use that term VERY loosely) my mother received for the DCIS she was diagnosed with back in 2000 was unlikely to have killed her, even if it had never been touched or treated in any way, whereas the radiation "therapy" she was given post-lumpectomy basically burned holes in her breasts and lungs and gave her a highly aggressive radiation-induced cancer that killed her decisively in 2009. Brilliant! Thanks MD geniuses.
She'd probably still be alive TODAY if it weren't for that unnecessary radiation. SHAME on any physician who ever recommends that for DCIS EVER AGAIN. I felt it was overkill at the time, but now I am certain. Radiation should only be used in cases where it is a certainty that the patient will die with out it - i.e. extremely rarely.
She'd probably still be alive TODAY if it weren't for that unnecessary radiation. SHAME on any physician who ever recommends that for DCIS EVER AGAIN. I felt it was overkill at the time, but now I am certain. Radiation should only be used in cases where it is a certainty that the patient will die with out it - i.e. extremely rarely.
22
I am very sorry for the loss of your mother to what sounds like an angiosarcoma, a very rare cancer which can be an extremely infrequent consequence of prior radiation therapy.
But the rest of you comment is a gross oversimplification of the state of medical knowledge. Every case needs to be decided on risk versus benefit analysis, not a wildly irresponsible generalization like "radiation should only be used in cases where there is a certainty the patient will die without it".
But the rest of you comment is a gross oversimplification of the state of medical knowledge. Every case needs to be decided on risk versus benefit analysis, not a wildly irresponsible generalization like "radiation should only be used in cases where there is a certainty the patient will die without it".
8
I read this article with great interest especially as a practicing pathologist who looks at a large number of breast biopsies yearly at my practice. Contrary to what the article says, biopsy is and will remain the gold standard for diagnosis of breast diseases. There are no other diagnostic modalities i.e. radiology, clinical history, physical examination, etc that can tell a difference between a malignant or benign / reactive condition as well as the tissue diagnosis ( biopsy ) does and that's a fact. The area that reportedly had poor correlation and interobserver variability was between the diagnosis of " atypia" vs. benign. What " atypia " refers to by and large includes three lesions, atypical ductal hyperplasia, atypical lobular hyperplasia and flat epithelial atypia. These are difficult to diagnose lesions that even the "experts " have disagreements on their definition. The actual biological course of these lesions is unknown and the potential treatments vary widely from excision to watchful waiting. Atypia though does not equal malignancy. The good news is that most of the practicing community pathologists , including myself, show these cases to their other colleagues in the practice or refer these cases for consultation to their expert colleagues at other larger academic centers for a second opinion. Unfortunately, this study clearly disallowed the community pathologists to consult on difficult cases which is the norm in almost all community practices.
33
I'm curious as to whether your practice's practice is standard practice and how many pathology reports are actually read by a contract player, oops I mean pathologist, in India or some other country? I would bet a lot of hospitals and breast centers prefer that that information does not get widely disseminated.
3
I am married to a practicing breast pathologist in a medium sized midwestern city. For this area the number for "how many pathology reports are actually read by a contract player, oops I mean pathologist, in India or some other country?" is zero. For biopsies especially there are a large number of legal, practical, and monetary reasons why this doesn't work. I understand that some radiology work can be outsourced but I have never heard of pathology being sent overseas for diagnosis. If you can find any citation to show otherwise please share it.
6
None Karen. No biopsies anywhere in the United States is read outside the United States. In order to practice medicine one has to be a licensed physician in the US, reside in the US and have completed an accredited residency in the US.
2
Until we understand the etiology and course of this disease a lot better than we do now, we will be stumbling around in the dark.
Instead of spending money on pink ribbons and mammograms we need to invest in basic research to advance the state of our understanding.
Instead of spending money on pink ribbons and mammograms we need to invest in basic research to advance the state of our understanding.
59
Scared or scarred? Is that the best that women can be offered? Men when the question is their prostate? The most disconcerting quote to occur in this piece is,''experts disagree about whether D.C.I.S. is cancer.''
The cynic in us all will be left wondering, "do cancer diagnosis with 'atypia' or cancer diagnosis where only D.C.I.S. is found go up approaching April 15? Or, do they peak around Sept. 15, when school tuition bills must be paid?
Do surgeons, radiologists, and experts have financial pressures that can influence their judgement? In a profit driven medical system the answer is probably 'yes.'
The cynic in us all will be left wondering, "do cancer diagnosis with 'atypia' or cancer diagnosis where only D.C.I.S. is found go up approaching April 15? Or, do they peak around Sept. 15, when school tuition bills must be paid?
Do surgeons, radiologists, and experts have financial pressures that can influence their judgement? In a profit driven medical system the answer is probably 'yes.'
8
These are unrealistic accusations since it is not the pathologist who benefits financially from follow up surgical procedures.
10
There's a reason they say doctors are "practicing" medicine, and this is a good example.
12
Even though this is decade-old news, women continue to be advised (and, as I have seen through my practice, coerced by malpractice-fearing MD's) into biopsy and treatment due to lack of full disclosure or misinformation.
I am glad to see it highlighted again: Perhaps it won't take another decade for this information to actually incite a change in diagnostic and treatment protocols.
I am glad to see it highlighted again: Perhaps it won't take another decade for this information to actually incite a change in diagnostic and treatment protocols.
16
Dear Margot - so many in my family have had breast cancer. You would be wrong about the worrying malpractice physicians and more correct about those attorneys seeking an easy living in malpractice. One death and you get a lottery. GROW UP. My family is full of both attorneys and physicians. Sorry, but the ones who seek to help others get my vote every time - the doctors.
8
What is completely missing in this article is differentiating between the kinds of biopsies. What was tested here in the first place by pathologists, the samples from fine-needle biopsies, hollow-needle biopsies or surgical biopsies.
Many women will once again again be more scared than reassured by reading an article like this.
Many women will once again again be more scared than reassured by reading an article like this.
14
I have had all 3 biopsies that you mention and I was reassured by this article. I have been diagnosed twice with atypical ductal hyperplasia and will gladly take the wait and see approach if faced again with the decision. Knowledge is not a bad thing.
7
Sometimes we have to choose between getting reassurance or getting the truth or at least somewhere closer to the truth. And sometimes, for some people in some circumstances, truth and reassurance are not synonymous.
3
Women have good cause to be "very scared" when confronting a diagnosis of "breast cancer". The first reason is fear of the disease itself...if it is present it is a serious health issue - and it is somewhat comforting to know that "When it came to invasive cancer — cancer that has begun growing beyond the layer of tissue in which it started, into nearby healthy tissue — the outside pathologists agreed with the experts in 96 percent of the interpretations, which Dr. Elmore called reassuring. They found the vast majority of the cancers."
And another major reason for fear is that 1) the diagnosis may be wrong - leading to unnecessary treatment or conversely, leading to no treatment when it was necessary and 2) that some small number of physicians (motivated by whatever) push their patients to accept a wide range of costly and often uncomfortable treatments.
In fact, many women still exhibit last century's attitude toward doctors, i.e. , "OK doc, I have this disease, do whatever it takes to fix me, I am in your hands."
And thirdly it might be justified to be fearful even if you are a most informed patient who is being treated by the most intelligent doctor, since even the best of us isn't "right" ALL the time. Life is uncertain, so if possible, try hard to prevent fear from leading the way.
And another major reason for fear is that 1) the diagnosis may be wrong - leading to unnecessary treatment or conversely, leading to no treatment when it was necessary and 2) that some small number of physicians (motivated by whatever) push their patients to accept a wide range of costly and often uncomfortable treatments.
In fact, many women still exhibit last century's attitude toward doctors, i.e. , "OK doc, I have this disease, do whatever it takes to fix me, I am in your hands."
And thirdly it might be justified to be fearful even if you are a most informed patient who is being treated by the most intelligent doctor, since even the best of us isn't "right" ALL the time. Life is uncertain, so if possible, try hard to prevent fear from leading the way.
2
Just about all people prefer certainty when making decisions as important as the ones they must make regarding many aspects of their health care, decisions with truly life altering consequences, such as whether or not to undergo major surgery, such as a mastectomy.
And, in the biopsy study being discussed, it is not at all clear that the discordance between the expert interpretations and those of the practicing pathologists was due to errors by the later. Even the experts had disagreement among themselves.
The fact is that many things in medicine are uncertain. To coin a cliche, medicine is a much an art as a science. Physicians don't always get it right, no matter how good they are. Nature is that way. Most often only hindsight is 20-20.
So, choose your doctors carefully, to get the best possible medical opinion. And, when the stakes are high, a second opinion is usually a good idea. But expect advice, not certainty. The best physicians are usually those that know the limitations of medicine, and present the options, probabilities, and choices, rather than a single "right" thing to do.
Making such tough choices is hard on all patients, including physicians when they become patients. But that's the way things are. As we learn more and master the mysteries of DNA - often called "precision medicine" - things will improve, probably a great deal.
But even with the best and newest tools, there will often not be certainty.
And, in the biopsy study being discussed, it is not at all clear that the discordance between the expert interpretations and those of the practicing pathologists was due to errors by the later. Even the experts had disagreement among themselves.
The fact is that many things in medicine are uncertain. To coin a cliche, medicine is a much an art as a science. Physicians don't always get it right, no matter how good they are. Nature is that way. Most often only hindsight is 20-20.
So, choose your doctors carefully, to get the best possible medical opinion. And, when the stakes are high, a second opinion is usually a good idea. But expect advice, not certainty. The best physicians are usually those that know the limitations of medicine, and present the options, probabilities, and choices, rather than a single "right" thing to do.
Making such tough choices is hard on all patients, including physicians when they become patients. But that's the way things are. As we learn more and master the mysteries of DNA - often called "precision medicine" - things will improve, probably a great deal.
But even with the best and newest tools, there will often not be certainty.
29
Six months ago by total chance found the smallest lump imaginable, lo and behold, barely stage 1, not spread. Unfortunately I have been vigilant about this my entire life, since my maternal grandmother died from it, as well as two maternal aunts, and one sister was ahead of me with a cancer diagnosis. She was braca positive; I was tested, and I am not carrying those gene mutatitions, fortunately for my 13 year old daughter.
What did I do? No hesitation at all-radical double masectomy. Yes its a big surgery, yes it was painful, yes it was scary. But I want to be here for my daughter and hopefully grandchildren, and my heart breaks to hear of lumpectomies that lead to years and years of testing, testing, testing and awful teeth gnashing stress- and sometimes worse news.
I am really puzzled by women who are so attached to their breasts they would take such a chance with their lives. I had pretty nice breasts (so I was told!), breast fed my daughter, etc. Yes there are scars- no doubt about it- but I am 100% pleased and confident with my choice.
Its not fair, its not right, but women need to look at their entire health picture.
What did I do? No hesitation at all-radical double masectomy. Yes its a big surgery, yes it was painful, yes it was scary. But I want to be here for my daughter and hopefully grandchildren, and my heart breaks to hear of lumpectomies that lead to years and years of testing, testing, testing and awful teeth gnashing stress- and sometimes worse news.
I am really puzzled by women who are so attached to their breasts they would take such a chance with their lives. I had pretty nice breasts (so I was told!), breast fed my daughter, etc. Yes there are scars- no doubt about it- but I am 100% pleased and confident with my choice.
Its not fair, its not right, but women need to look at their entire health picture.
29
My beloved older sister, who had a double mastectomy, radiation and chemo still died after a few years of remission when the cancer returned in her bones. You can take the most radical of steps, but there is never any guarantee.
11
I don't know that all women who choose not to have a radical double mastectomy do so because they'd rather have breasts than life-saving surgery. Some people would rather not accept the risks of major surgery when the other options are so much less invasive and dangerous.
19
No need to put down women who value their breasts more than you do and look for certainty and other alternatives.
In Canada, they cut it off and then say sorry, you don't have cancer, you never had cancer. At least that is how it happened to me.
In Canada, they cut it off and then say sorry, you don't have cancer, you never had cancer. At least that is how it happened to me.
3
I am a veterinary pathologist and die hard, decades long reader of the New York Times. I am surprised that the tag line for this article is "Doubts on Biopsies as the Gold Standard for Breast Cancer". While I am not aware of the official, FDA definition of gold standard, I beg to differ on the Times' interpretation of the JAMA article conclusions. Biopsy often is THE gold standard- i.e. the best way to characterize a disease process (or lack thereof). Of course, a biopsy is only complete when interpreted in conjunction with clinical history, clinical interpretation, ancillary diagnostics (such as evaluation for tumor suppressor gene and oncogene mutations) etc. Interpreted in this manner, a biopsy is as good as it gets. As many readers have already stated, an uncertain diagnosis from a biopsy is a fact of life, unfortunately- sometimes, despite all our collective best efforts, there isn't a definitive answer. EVERYONE (patients, clinicians, surgeons, pathologists, et al) dislikes this- we all recognize that this impedes decision making and makes it difficult for a patient to move on. Historically, some currently easily treatable diseases were undefined and fatal. With continued collaboration, particularly in the realm of comparative medicine, the day will come when this discussion will be part of a narrative that ends with the development of effective, appropriate, tolerable, inexpensive treatments for breast cancer.
27
"Abby Howell chose to have a biopsy when a mammogram showed some calcification two years ago. Instead of being definitive, the biopsy found atypia — abnormal duct cells that are not cancerous but which some doctors recommend having removed." Why remove "abnormal cells" if they are not injuring one's health? "Abnormality" on its own is not a reason to do anything. But"some doctors" recommend that you pay them to do this, and some patients are dumb enough to pay them.
10
The atypical cells in "atypical ductal hyperplasia" are not the cells that are going harm one. Whether or not one gets additional tissue removed when ADH is diagnosed depends on what sort biopsy it is seen in. When ADH is seen in a small needle core biopsy, typically additional tissue is removed because there ADH can been seen in association with malignancy and there is a chance that when the more of the surrounding tissue is removed that a more worrisome lesion such as DCIS or invasive carcinoma will be seen. If ADH is seen on a larger tissue sample where more of the surrounding tissue can be seen, additional surgery is not needed typically. This point is not mentioned.
12
Much research aimed at the diagnosis of smaller and smaller cancers, resulting in improved cure rates, has led to the frequent finding of these varieties of not-normal, but not-yet-cancer lesions. Even the three text-book-writing experts had to consult with each other to reach a consensus on many of the cases.
The suspicion or diagnosis of breast cancer is not a medical emergency. There is abundant time for discussion and second or multiple opinions on a biopsy, which are routine and automatic with most pathologist groups. A patient should never be hurried through a series of expensive and invasive procedures, but should be offered thorough and measured counseling of all options, a service which many community breast cancer services already provide.
The suspicion or diagnosis of breast cancer is not a medical emergency. There is abundant time for discussion and second or multiple opinions on a biopsy, which are routine and automatic with most pathologist groups. A patient should never be hurried through a series of expensive and invasive procedures, but should be offered thorough and measured counseling of all options, a service which many community breast cancer services already provide.
22
Headline seems misleading. Biopsies still seem like solid assays you just need to make sure you have the right person interpeting them, and the right person might not be at your local county hospital.
13
What is missing in past articles and in this article is identifying the grade of the DCIS. My mothers DCIS spread to her lymph nodes and she had a poor prognosis. Having a history of breast cancer with my mother, sister, cousin and myself, I was aggresively treated. Commenters: please stop the judgement regarding correct treatment(s). Every case is uniquely different.
27
AW; sorry to hear about your loss. However, your mother must have also had undiagnosed invasive cancer which metastasized, since DCIS, by definition, does not have the ability to spread. Just wanted to make sure that readers understood that DCIS is not invasive, and that there is even controversy as to whether it should in fact be called cancer.
7
Biopsies, in addition to repeat mammograms and ultrasounds, can be repeated at certain intervals. Surgery is of course irreversible; why rush into it? The other interesting point is that routine autopsies, over the years, have shown various cancers which did not spread, let alone kill the person. How about correlating findings on those non-lethal breast tumors with the current "best practice" information on DCIS and atypia? Could be there's a minefield of such information waiting to be applied.
9
How do we know whether the experts are better? Believe it?
A. Can experts reproduce each other blindly, without prior discussion and deliberation same way they compare themselves to "non_experts". Show the evidence that it is happening.
B. Are expert diagnoses lead to better patient outcomes -i.e. longer and healthier lives after treatment or unnecessary treatments avoided? Evidence, please.
C. lobbying for all breast biopsies to be read twice by the experts will lead to double billing, Unless you show that the outcomes are way better between the experts and non-experts, the differences in opinions do not matter and occur at random due to a grey zone diagnostics and limited capacity of humans to read "the meaning" behind the microscopic slides.
A. Can experts reproduce each other blindly, without prior discussion and deliberation same way they compare themselves to "non_experts". Show the evidence that it is happening.
B. Are expert diagnoses lead to better patient outcomes -i.e. longer and healthier lives after treatment or unnecessary treatments avoided? Evidence, please.
C. lobbying for all breast biopsies to be read twice by the experts will lead to double billing, Unless you show that the outcomes are way better between the experts and non-experts, the differences in opinions do not matter and occur at random due to a grey zone diagnostics and limited capacity of humans to read "the meaning" behind the microscopic slides.
15
Three years ago I had a double mastectomy performed by Dr. Port (mentioned in this piece) after a biopsy said I had DCIS. All the research that has come out since then has made me endlessly second guess that enormous operation. Did I do the right thing? I will never know but I can tell you that I live with the scars, the loss of sensation, the idea that I now have a body that isn't mine every day. The trauma of this surgery is not to be underestimated. You don't 'heal.'
36
I too had the same diagnosis and operations. The mastectomies and reconstructive surgeries were painful, and I continue to deal with pain. But I would gladly trade my breasts again for the piece of mind I received in return; I wanted to do everything possible to decrease risk of invasive disease or recurrence, knowing there are no guarantees. That said, how many men, experts included, would be content with a watch-and-wait suggestion if they had precancerous cells in their testes and no assurances that a dreadful disease wasn't simmering?
8
Actually, watch and wait (active surveillance) is a management for prostate cancer, based on age, life expectancy, and cellular atypia, chosen by many men each year. http://www.cancer.gov/cancertopics/pdq/treatment/prostate/HealthProfessi...
On the other hand, testis are removed based on ultrasound findings of an intratesticular, no biopsy. How many women would be content with that?
Different management for different cancers with different biological behavior and spread in different organs.
On the other hand, testis are removed based on ultrasound findings of an intratesticular, no biopsy. How many women would be content with that?
Different management for different cancers with different biological behavior and spread in different organs.
5
This is a very personal decision that each woman must make for herself. Thirteen years ago I was diagnosed with malignant microcalcifications and was given the option of Lumpectomy with radiation and tamoxifen vs. Mastectomy. My mother had breast cancer (unlike me she had a palpable lump) and underwent a terrible disfiguring radical mastectomy in 1971. We were grateful that the surgery saved her life, however she was never the same physically. I was told by my surgeon at NY Presbyterian that the survival outcomes of Lumpectomy with radiation vs. Mastectomy were identical. I had clear lymph nodes, and the cancer was slow growing and non-aggressive. I chose Lumpectomy. To be honest, I was more concerned about the link with ovarian cancer and was tested for BRCA (it was negative). Had it been positive I would have definitely chosen Mastectomy.
Two years ago I had an "abnormal" mamogram requiring a biopsy in my other breast. It was benign. Might I get cancer again? Sure, but it won't be from the tumor excised 13 years ago. It will be an entirely new cancer. My risk is now the same as women my age who have never had cancer. I think the most important thing is to find a good doctor you can trust and become as informed as you possibly can on your options. Only you know what it will take to make you feel at peace.
Two years ago I had an "abnormal" mamogram requiring a biopsy in my other breast. It was benign. Might I get cancer again? Sure, but it won't be from the tumor excised 13 years ago. It will be an entirely new cancer. My risk is now the same as women my age who have never had cancer. I think the most important thing is to find a good doctor you can trust and become as informed as you possibly can on your options. Only you know what it will take to make you feel at peace.
1
This is a good article. It highlights that pathology is an interpretive field and therefor subject to a low probablilty of error. Second opinions should always be considered in all areas of medicine when significant diagnoses and life-changing treatments are conisidered.
That said, I find the structure of the cited medical study somewhat odd. It's stated goals were to compare the diagnostic accuracy of expert to non-expert pathologists. Yet according to this article, the three expert pathologists were allowed to come to consensus diagnoses, while the outside pathologists were not allowed to share the difficult cases with their colleagues. That is simply not the way pathology is practiced. As a pathologist myself, I know it is very common to share difficult cases with colleauges, and if needed, then send them on to experts. I believe it could have been a better study if the chosen methodology better reflected actual practice patterns.
That said, I find the structure of the cited medical study somewhat odd. It's stated goals were to compare the diagnostic accuracy of expert to non-expert pathologists. Yet according to this article, the three expert pathologists were allowed to come to consensus diagnoses, while the outside pathologists were not allowed to share the difficult cases with their colleagues. That is simply not the way pathology is practiced. As a pathologist myself, I know it is very common to share difficult cases with colleauges, and if needed, then send them on to experts. I believe it could have been a better study if the chosen methodology better reflected actual practice patterns.
32
Doubts on biopsies? Doubts on the entire screening process! Breast cancer screening and treatment is one of the biggest medical scams in history. All of a sudden we have these X-ray machines that can detect "lumps" in breast tissue and it is promoted to concerned women as a mandatory screening tool. Of course all it is is another way to make money. It feeds directly into the pockets of surgeons, oncologists and "search-for-a cure" foundations. Everyone made money in the Medical-Industrial Complex. More women were subject to unneeded surgery and chemotherapy than were ever saved. Of course, the gullible will believe that without the screening from their saintly doctor, they would have died of cancer. Of course! That's what makes it such a great scam.
47
Agreed!
8
What is your evidence for these assertions?
5
I think you're at least partly correct.
1
Millions of hapless women have had their breasts cut off, unnecessarily, thanks to this technology. My mother was one of them. But, I will not be one of them, I swear.
21
That's what I said- up until the dark night of the soul when I had a Stage 1 diagnosis...
5
Ah, the poor ladies nowadays get bombarded with so much conflicting information about breast cancer diagnosis and treatment. It is enough to drive anybody a little bonkers. It is as though each woman has to act as her own expert pathologist and treatment specialist.
In the end, a decision must be made. And not making a decision is also a decision. I don't believe there are any 'right' answers here, other than to try not to worry too much once a course of action is decided upon.
16
Medicine is full of grey areas. As mentioned in the article the best, inexpensive answer would be to get a second opinion of the same slide of tissue. That would prevent unnecessary surgeries and treatments but being pro-active by having regular screenings. But then again mammograms and ultrasound results may not be conclusive and present a new set of grey areas not to mention increased health expenses. And so the saga continues. In the study mentioned, results of pathologists were compared to that of a panel of experts. The results of the experts served as the 'Gold Standard'. What if their conclusions were not correct?
3
If it is a borderline case, would it not result in a lumpectomy without chemo or radiation? A lumpectomy leaves a slight imbalance between the two breasts but that is about all-- so why not go ahead and have peace of mind with a slightly deformed breast , it is not an amputation as a mastectomy is.
5
I had a lumpectomy and radiation and my affected breast is significantly smaller and most importantly much higher than my other breast. No one warned me that radiation would leave me so very imbalanced. Now I am offered reconstruction surgery-which seems scary.
1
First, do no harm. The pathologists diagnosed abnormality in 13% of the women whose tissue was normal -- that's more than one in eight normal biopsies misdiagnosed as abnormal. And a woman with a master's in public health regrets her biopsy because of the stress it's caused. It all reaffirms my personal decision to avoid screening mammograms entirely. The risks are real, and the benefits have been vastly oversold.
26
Believe me. The stress of the biopsy is nothing compared to the stress of a diagnosis. And not having a screening mammogram, while it is a choice, is hiding one's head in the sand. If you can feel a lump, you're less likely to have early-stage disease.
11
No, I'm not "hiding my head in the sand." I know my personal risk factors, I've read the studies on the risks and benefits of mammograms, and I've made a rational choice. Most people do not understand what over-treatment for breast cancer means. It's not just unnecessary biopsy. It's having a lumpectomy, mastectomy, radiation, and/or chemotherapy for a clump of "abnormal cells" that wold have never developed into anything at all. Look at the data and make your own choice. But don't assume that I'm irrational if my choice is different from yours.
13
OK Keen but you're not addressing the question. Is the tiny thing detectable only by screening mammogram cancer, is it dangerous, is it actually going somewhere, or not? If the mammogram comes up with something, is it "early-stage disease" or is it nothing?
That the rates of "cures" of "early-stage disease" have marched up in lockstep with "early cancers diagnosed" suggests that some of those "cancers" were not cancer at all.
That the rates of "cures" of "early-stage disease" have marched up in lockstep with "early cancers diagnosed" suggests that some of those "cancers" were not cancer at all.
8
As a practicing pathologist who interpretes breast biopies on a regular basis, I can say it is probably one of the most difficult areas in my specialty, especially the diagnosis of atypical ductal hyperplasia. We, fortunately, have a breast expert in our practice. The three of us in the group must agree on every case or we send it out for an academic breast pathologist's consultation. The most important reason is to be right for the patient's sake. The second is that breast cancer has such an emotional component and, therefore, a high chance for litigation. I'd never interpret a biopsy solo.
28
Articles such as this one do nothing to alleviate women's confusion or concern and in fact exaccerbate both. Enough of the "have a mammo/don't have a mammo" and "to biospy or not to biopsy" bull. Unless and until women have more diagnostic weapons at their disposal, these tests are it and they should be used. Do the "experts" quoted here think that every woman has access to the kind of expertise they recommend? We don't. We are forced to rely on the very tools that, every couple of years or so, we're told may or may not be effective. Do these same experts think that walking around with abnormal or precancerous cells in their breasts is any less stressful for women than undergoing a biopsy? It ain't. Most of us understand that cancers are complicated diseases. But why, in 2015, is breast cancer still such an undiscovered country? Enough.
14
There is a very important message for politicians in this story: pre-existing conditions and Obamacare (Affordable Care Act).
If Obamacare is repealed the tests Ms. Howell had would again be used to deny her future insurance reimbursement should she ever be diagnosed with cancer - even though the tests showed she did not have cancer. She would be denied due to a "pre-exisiting condition," even though that assertion is specious.
I speak from experience beginning 25 years ago with nearly the same diagnosis affecting our insurance. This became moot with the passage of ACA.
On a scientific note, lower cost genetic sequencing of tissue samples will eventually enable more accurate molecular diagnosis but it will take years for the long-term survival studies to confirm the choices made by patients and doctors.
If Obamacare is repealed the tests Ms. Howell had would again be used to deny her future insurance reimbursement should she ever be diagnosed with cancer - even though the tests showed she did not have cancer. She would be denied due to a "pre-exisiting condition," even though that assertion is specious.
I speak from experience beginning 25 years ago with nearly the same diagnosis affecting our insurance. This became moot with the passage of ACA.
On a scientific note, lower cost genetic sequencing of tissue samples will eventually enable more accurate molecular diagnosis but it will take years for the long-term survival studies to confirm the choices made by patients and doctors.
24
The house already approved pre-existing conditions. Get the facts before spreading your fears as facts
2
Yet one more reason for most of us to avoid mammography before age 50.
8
I am a Stage IV Breast cancer patient. So low risk at original diagnosis (2007) that chemo was not recommended. I didn't think to get a 2nd opinion, I was so relieved.
In 2012 the disease had spread to my bones and in 2013 to my brain. With the help of Herceptin, I carry on, but I have become much more skeptical of diagnostic testing and pathological interpretations.
Recently pain returned to my hip. The 1st interpreter of the MRI said definitely a return of metastatic cancer, the 2nd said no, it looks more like necrosis due to radiation 2 1/2 years ago. I was sent to a University expert. The fellow who saw me first said, yes indeed, this is recurrent metastatic cancer. The doctor said no, this is AVN, avascular necrosis.
For now, I'm swimming every day and waiting to see if things get better or worse. My oncologist does not want to change my medicine unless I show definite signs of progression. The orthopedic surgeon will do a hip replacement if things get worse. Either way, it seems that I'm still in the "guessing game" phase of this disease.
In 2012 the disease had spread to my bones and in 2013 to my brain. With the help of Herceptin, I carry on, but I have become much more skeptical of diagnostic testing and pathological interpretations.
Recently pain returned to my hip. The 1st interpreter of the MRI said definitely a return of metastatic cancer, the 2nd said no, it looks more like necrosis due to radiation 2 1/2 years ago. I was sent to a University expert. The fellow who saw me first said, yes indeed, this is recurrent metastatic cancer. The doctor said no, this is AVN, avascular necrosis.
For now, I'm swimming every day and waiting to see if things get better or worse. My oncologist does not want to change my medicine unless I show definite signs of progression. The orthopedic surgeon will do a hip replacement if things get worse. Either way, it seems that I'm still in the "guessing game" phase of this disease.
23
I am sorry to hear of the ordeal that you have been going through. Unfortunately, some cases are going to slip through despite the best efforts of the medical system and the doctors and technicians who staff it. Cancers are among the most insidious and unpredictable diseases, and it is impossible to say with certainty what somebody's risk is going to be no matter what tests are done.
6
I've had AVN and a hip replacement. Get another opinion on that hip! An MRI should be able to show AVN clearly. And get your hip replaced. Best thing I ever did. If it's AVN, physical therapy isn't going to do a thing. But a new hip will give you a new lease on life.
My regular screening mammogram revealed calcifications and a biopsy was recommended. The subsequent stereotactic core needle biopsy revealed DCIS as diagnosed by "one of the best pathologists in the province." No rush for surgery which was done more than two months later. I opted for a mastectomy and to everyone's surprise, the pathology report showed a 1-2 cm area of invasive ductal cancer (beside the previously diagnosed
DCIS) which had not been detected in any of the nine core samples at the time of biopsy. Given the new diagnosis of invasive cancer, I underwent a second surgery to have my axillary lymph nodes removed and biopsied (negative). Having worked in the past as I cancer research nurse, I am left wondering if in fact the core biopsies of calcified areas seen on mammogram are TOO localized in that they do not sample the surrounding tissue which may contain microscopic cancer not detectable on mammogram.
DCIS) which had not been detected in any of the nine core samples at the time of biopsy. Given the new diagnosis of invasive cancer, I underwent a second surgery to have my axillary lymph nodes removed and biopsied (negative). Having worked in the past as I cancer research nurse, I am left wondering if in fact the core biopsies of calcified areas seen on mammogram are TOO localized in that they do not sample the surrounding tissue which may contain microscopic cancer not detectable on mammogram.
14
The biopsy never has been the gold standard. That would be the pathologic specimen. Finding a low kappa value indicating poor reproducibility between pathologists in this area is not news.
Unfortunately, the endless quest for catchy headlines will probably leave some women less likely to submit to biopsy for mammographic abnormalities.
Unfortunately, the endless quest for catchy headlines will probably leave some women less likely to submit to biopsy for mammographic abnormalities.
11
Define the difference beween biopsy and pathological specimen - it is very confusing!
What B is referring to is a biopsy using a coring device, which produces small cylinders of tissue that can be examined microscopically. Prior to this, the area in suspicion was surgically removed, producing a "specimen". The entire area of suspicion, along with the surrounding tissue, are removed. This allows pathologists to determine if there is a tumor anywhere in the area of concern.
3
Here's the thing. All of this costs money. Many of us don't have that kind of money. Why do I say that? Because medical care, even with insurance, has become very expensive. We never know how much it will cost us in terms of money or in terms of our personal well being. Not only that but our health insurance doesn't always allow for us to consult with an expert even if that's what needed to determine whether or not those cells are cancerous, atypical, or just impossible to classify.
As a 56 year old woman I've avoided doctors as much as possible for two reasons: they are often patronizing towards women and I'm always hit with unexpected expenses. I remember when mammograms were being touted as THE WAY to catch all breast cancers before they spread to the adjacent tissues or metastasized elsewhere. I thought it was a good idea until I realized that there were many cases where women were being alarmed and cut up for no good reason but a questionable result. The wait and watch is equally bad because cancer has a nasty habit of spreading once it reaches a certain size.
I don't know the answer here but it seems to me that we need to improve our health care system, teach patients (before we become patients) what the terms mean and explain that there are no definite answers. Unfortunately we all like definite answers so the messiness of life in general can drive us crazy.
As a 56 year old woman I've avoided doctors as much as possible for two reasons: they are often patronizing towards women and I'm always hit with unexpected expenses. I remember when mammograms were being touted as THE WAY to catch all breast cancers before they spread to the adjacent tissues or metastasized elsewhere. I thought it was a good idea until I realized that there were many cases where women were being alarmed and cut up for no good reason but a questionable result. The wait and watch is equally bad because cancer has a nasty habit of spreading once it reaches a certain size.
I don't know the answer here but it seems to me that we need to improve our health care system, teach patients (before we become patients) what the terms mean and explain that there are no definite answers. Unfortunately we all like definite answers so the messiness of life in general can drive us crazy.
18
To a practicing pathologist, this study could be called "In other news, water is wet." The areas of breast pathology discussed are known to be some of the most difficult. Everyone wants medicine to be definitive and black and white, but that is not always the case. The vast majority of pathologists know that distinguishing between DCIS, atypical hyperplasia and the other variants discussed here can be difficult. Most will consult an expert breast pathologist or a colleague within his or her practice for cases such as these. When I was a practicing pathologist, I did. Many practices have built is safeguards such as automatic second opinions for certain diagnoses. However, to a layperson, a headline such as "Breast Biopsies Leave Room for Doubt" and "Doubts on biopsies as the gold standard for breast cancer" are unnecessarily misleading. To be clear, I don't know any surgeon who will do definitive surgery (such as a mastectomy) without a tissue diagnosis, which of course means biopsies will always be necessary. In addition, in all of pathology (not just breast pathology), there will always be biopsies that are not definitive. There will always be gray areas. Sometimes these gray areas will require additional studies beyond a second read of a slide. Until there is some type of magical diagnosis machine, biopsies will be the gold standard for diagnosis. This doesn't mean that there will be no gray areas or that every biopsy will have a definitive answer.
101
"This doesn't mean that there will be no gray areas or that every biopsy will have a definitive answer." LIKE REAL LIFE, indeed.
The problem isn't that there is a place for biopsies and other tests, the danger is the OVER-reliance at the expense of things that we should be doing such as generally healthy lifestyle. But even this has become less "accessible" as we put increasingly more trust in science because science does seem to perform miracles. The trick is to keep our innate "life-force" alive that we all are born with, which will help us with our health much more than being drawn into an addictive attitude into science.
The problem isn't that there is a place for biopsies and other tests, the danger is the OVER-reliance at the expense of things that we should be doing such as generally healthy lifestyle. But even this has become less "accessible" as we put increasingly more trust in science because science does seem to perform miracles. The trick is to keep our innate "life-force" alive that we all are born with, which will help us with our health much more than being drawn into an addictive attitude into science.
I am so glad that there are some informed opinions as part of these comments. I agree that the media marketing of this finding has been sensationalized to the point of being irresponsible. Nature does not come binary and labelled. All diseases occur and manifest themselves as a spectrum, and experts do honestly disagree. Many areas of pathology are routinely subjected to second opinions, peer consultations or consensus panels due to their inherently difficult diagnosis, variable biology of the disease and the possibly devastating consequences if over- or under-diagnosed (e.g. pigmented lesions).
The REAL gold that should have come out of this study would have been to follow the women who got the results of D.C.I.S. and atypia and to determine whether they developed malignancies later on. I too think we are "surgery happy" and treatment overusers in this country.
17
That would be a great study. The problem is getting people with a diagnosis of ductal Carcinoma in situ into the " non-treatment " arm of the study. Good luck.
12
This is known from the NSABP B-17 trial, which randomized patients to resection +/- radiation treatment afterwards. In the resection only group, despite having the DCIS removed, they had a 17% risk of invasive breast cancer in the same breast within 12 years. We can thus assume at least this risk of invasive breast cancer in patients who did not have the DCIS removed. It would not be ethical to conduct a trial that randomized patients to resection or not due to the known high risk of invasive breast cancer without resection.
3
This is not news, uncertainty is an integral part of medicine. It's something you manage, not something you can eliminate.
Despite the many advances of the past century, predicting exactly what will happen in the actual biological system sitting on the exam table in front of you is impossible except in broad strokes. Biological systems are non-linear, full of redundancies and overlapping pathways. Our understanding remains maddeningly incomplete. And yet, you are forced to make a series of binary decisions, operate or not. Chemo or not. Radiation or not.
And you know, even if you don't like thinking about it, that you will occasionally be wrong; that even when you're right, things can go horribly wrong; that nothing is free and that nothing is guaranteed; that even when you pass the buck and "let the patient decide" you've made a choice that will have consequences that both you and the patient will have to live with.
Despite the many advances of the past century, predicting exactly what will happen in the actual biological system sitting on the exam table in front of you is impossible except in broad strokes. Biological systems are non-linear, full of redundancies and overlapping pathways. Our understanding remains maddeningly incomplete. And yet, you are forced to make a series of binary decisions, operate or not. Chemo or not. Radiation or not.
And you know, even if you don't like thinking about it, that you will occasionally be wrong; that even when you're right, things can go horribly wrong; that nothing is free and that nothing is guaranteed; that even when you pass the buck and "let the patient decide" you've made a choice that will have consequences that both you and the patient will have to live with.
28
Microscopic diagnosis by pathologists is essentially pattern recognition by the trained eye. Even at it's best, it is subject to the foible's of the limits of human mind , whether it is that of an "average" or " academic" pathologist as illustrated by by original 75% agreement among the panel members. Pathologic diagnosis is not the same as an instrument spitting out numbers for a blood test. It is a "qualitative" interpretation and is best done in the context of the clinical situation.The key word should be consensus, among pathologist, clinician and the patient given this limitation.
15
This study does not reflect actual practice, and therefore no real conclusions can be drawn. I retired from an active general surgery practice in 2010 (about 60
% surgical oncology and about 30% breast surgery), and a pathologist who looked at one slide per case would not have lasted a month in our institution. We routinely referred unclear cases to outsides institutions for review, and always sent far more than one slide. I don't see what this uproar is about. If we want to discuss when to to breast biopsies, and we should discuss that, it should be in real world terms. There is no test in medicine, invasive or noninvasive, that is 100% accurate. The risk of breast cancer is very real, and we should take it very seriously. Lives are at stake. Any intervention on any patient should be weighed as a risk/benefit discussion. I learned this in medical school in the 1970's and the principle hasn't changed.
% surgical oncology and about 30% breast surgery), and a pathologist who looked at one slide per case would not have lasted a month in our institution. We routinely referred unclear cases to outsides institutions for review, and always sent far more than one slide. I don't see what this uproar is about. If we want to discuss when to to breast biopsies, and we should discuss that, it should be in real world terms. There is no test in medicine, invasive or noninvasive, that is 100% accurate. The risk of breast cancer is very real, and we should take it very seriously. Lives are at stake. Any intervention on any patient should be weighed as a risk/benefit discussion. I learned this in medical school in the 1970's and the principle hasn't changed.
38
We have to do the best we can in this situation -- where doctors are uncertain about the best treatment for each individual, where one must balance the risks versus the benefits before choosing a treatment. There are diseases which are virtually completely understood, where treatment modalities are low risk, where diagnosis is almost unanimous. Breast cancer is not one of these. Our desire for certainty is understandable, and when a person has cancer she or he is scared enough without being told something that begins "In 48% of the cases..." But that's the reality.
6
A biopsy is a bit like the three blind men trying to figure out what the elephant looks like. The biopsy only retrieve cells in areas identified by MRI or breast XRays where there may be potential abnormalities, the pathologists can only draw conclusions on the area examined in the biopsies, but not all areas of the breast. Many women who opt for less invasive procedures such as lumpectomy has had to go back to additional surgeries either on the same breast or the other breast.( which is consider a different finding and not a recurrence). But seriously, if you find abnormality in one breast, what are the likelihood that you will also find problem in other areas of the same breast, or the other breast since the same environmental and genetic factors are still at work! For us older women who do not feel that their self-image is irretrievably "scarred" by the loss of her breasts, a more drastic choice may be a better way to go than going back for frequent MRI and breast exams that you suspicious or non-conclusive.
12
This problem may be related to what is called "defensive medicine," the tendency of doctors to err on the side of caution as a bulwork against being sued for failing to pursue every possible diagnostic means to rule out the presence or spread of cancer. So long as the threat of lawsuits persist, some inadvisable or unnecessary tests and procedures will be unavoidable.
12
There is little evidence that defensive medicine affects these kinds of decisions -- http://timesleader.com/news/local-news/50660118/Malpractice-insurance:-F...
2
I think that's a bit cynical. Obviously, some doctors react that way, but the difference in the findings between the panel of experts and those other practising pathologists was not driven by fear of being sued. They were participating in a research study, not recommending treatment for a particular patient. It would be interesting to know if the findings would have been different had the doctors involved believed they were reporting findings for a real patient. Would the tendency to err on the side of caution influence them? Nevertheless I don't beleive that that tendency, when it is present, can be entirely attributed to practicing defensive medicine or fear of lawsuits. In fact, I think many patients would want their doctor to err on the side of caution where the possibility of an invasive cancer exists. But if a doctor makes a serious medical error, why should they not be sued? You seem to be suggesting that a doctor's judgement and skill would somehow be enhanced if no one could sue them.
4
If what you say were true, then the majority of errors would be false positives and not equal false positives and missed diagnoses. I don't think that is what the data show.
4
Surgery and radiation are the only treatments? What about chemotherapy?
Chemotherapy is systemic and since DCIS is never invasive, chemo is never given for this as it would not have any effect whatsoever. Surgery (mastectomy or lumpectomy) and radiation is given and then anti hormonal therapy if the cancer is found to be estrogen positive.
3
I was diagnosed in October at MD Anderson's with invasive breast cancer ER+/PR+/Her2+ And DCIS and later that month also diagnosed with Paget's Disease at The Royal Marsden where I would undergo treatment. I delayed having surgery and went ahead with 12 weeks of taxol and 4 injections of Herceptin. Now not only is my invasive Cancer gone according to ultrasounds and mammograms, a Sterotactic biopsy shows the DCIS is gone! Either it was drugs or a miracle! Have started tamoxifen will undergo radiation BUT no surgery! We are all different in how we react to treatments.
8
I was just treated at The Royal Marsden for invasive Cancer, Paget's Disease and DCIS (which was diagnosed at MD Anderson) I delayed surgery and after 12 weeks of IV taxol and 4 injections of Herceptin, I had another round of Sterotactic biopsies and a nipple biopsy. No DCIS and no invasive Cancer could be found in the biopsies, or with ultrasound or mammograms. So for now no surgery. I guess we are all unique.
I have practiced pathology for 33+ years. I have been saying for nearly all that time that "atypical duct hyperplasia" (ADH) of the breast is an unscientific diagnosis and should be abandoned. The study cited in this article is nothing new. Pathologists have known for decades that the distinction between ADH and ductal carcinoma in situ (DCIS) is not reproducible from one pathologist to another. Any distinction that is not reproducible should be tossed on the trash pile of hypotheses that cannot withstand rigorous testing. I am hopeful that this article will finally put an end to this troublesome and counterproductive disease terminology.
24
While 100% of ADH does not progress to invasive ductal cancer, 100% of invasive breast cancer was first in situ.
3
The information in this article is not really new. It has been recognized for years that , even among breast pathologists, that it can be difficult to distinguish between Atypical Ductal Hyperplasia(ADH) and Ductal Carcinoma In Situ(DCIS). What is important is what percentage of those with ADH on a core needle biopsy really have DCIS or "Invasive" breast cancer in the tissue removed at surgical excision or "lumpectomy". How many with DCIS on core needle biopsy have "Invasive cancer" on the surgically excised tissue. Good Pathology groups do built in second opinions and good breast programs do Multidisciplinary Breast Conferences that include Pathologists , to prospectively review thee cases before any surgery is done. We need to strive to continue to find cancers early when they are more easily treated or even prevented. The last paragraph of your article that the patient avoid the biopsy is the wrong message. The right message is that patients should be evaluated and treated in centers adhering to the highest standards and accreditations . See the COC and NAPBC sites.
14
I am one of many women who has ridden this roller coaster. Mammograms, ultrasounds, MRIs, 6 month followups, inconclusive needle biopsies, surgeries to remove things that were not cancer or even dangerous but which could "complicate" future screening. And then there's the pandora's box of genetic testing! If you're negative for BRCA, there's a whole bunch of gene mutations out there that we know something about, but not enough to recommend anything except, maybe, more screening. Keep digging long enough and they will find a reason to screen you more frequently, which means more false positives, more inconclusive answers.
Now add to that list: second opinions because you can't trust a biopsy either.
And then there's the little matter of that $6000 family deductible. Long chains of inconclusive results are very, very expensive...
But I should be grateful! Women a generation ago didn't have all these chances and choices! Well, maybe. My mom is dying of breast cancer. When she sees the screening nightmare and anxiety my sister and I have gone through, she says she's grateful that she didn't have our "choices," because she would have died of a heart attack long before the cancer got her.
Now add to that list: second opinions because you can't trust a biopsy either.
And then there's the little matter of that $6000 family deductible. Long chains of inconclusive results are very, very expensive...
But I should be grateful! Women a generation ago didn't have all these chances and choices! Well, maybe. My mom is dying of breast cancer. When she sees the screening nightmare and anxiety my sister and I have gone through, she says she's grateful that she didn't have our "choices," because she would have died of a heart attack long before the cancer got her.
65
For those of us pathologists in practice this study is not really new information. We have always known that atypical ductal hyperplasia and atypical lobular hyperplasia is a "gray zone" without clear boundaries. We pathologists would love to have better objective criteria for these diagnostic categories. Not only that, it is not clear to patients and clinicians what to do about this diagnosis so more research is needed to better define which atypical findings are high or low risk. Ductal carcinoma in situ also has different implications depending on the morphology and extent of disease. Here, all cancers, ductal carcinoma in situ and atypical hyperplasia are reviewed by two pathologists.
13
The problem is this panel of so-called "breast experts" keeps sub classifying breast lesions when there is no real understanding of what the significance of any of theses lesions are. Even DCIS and LCIS have a lifetime risk of developing into invasive carcinoma in only 25-30% of cases. The other lesions are probably well below 5%. One could argue that these mildly atypical lesions shouldn't even be mentioned in the pathology report.
In the future there should be a better way to classify these lesions based on molecular analysis. Even invasive lesions cannot be fully characterized by morphology. But we already know this--which is why we perform hormone receptor and HER2 studies, in addition to checking the proliferation index.
In the future there should be a better way to classify these lesions based on molecular analysis. Even invasive lesions cannot be fully characterized by morphology. But we already know this--which is why we perform hormone receptor and HER2 studies, in addition to checking the proliferation index.
3
Would the expert pathological interpretation make a difference to the patient?
This study illustrates the dilemmas we will face as the diagnosis of disease becomes increasingly more sensitive, with attendent increases in costs, procedures, adverse effects, and over treatment.
The study concludes that, because of differences in interpretation between outside pathologists and experts, we must worry about improper treatment. The implication is that experts should review all pathologic specimens, resulting in greater health care utilization.
The real question is does it matter; does expert reading of pathology slides make a difference to the patient. This study does not address that question.
The cases where DCIS was missed by the outside pathologist may represent a lower risk, harder to detect subset of DCIS. These untreated women will continue to be screened, which may subsequently identify DCIS. In the cases where DCIS was falsely identified by the outside pathologist, the subsequent resection will allow closer examination of the tissue, and allow a definitive diagnosis.
As we seek to control the growth in health care costs we must ask ourselves whether increased diagnostic testing and treatment actually make a difference to the patient.
This study illustrates the dilemmas we will face as the diagnosis of disease becomes increasingly more sensitive, with attendent increases in costs, procedures, adverse effects, and over treatment.
The study concludes that, because of differences in interpretation between outside pathologists and experts, we must worry about improper treatment. The implication is that experts should review all pathologic specimens, resulting in greater health care utilization.
The real question is does it matter; does expert reading of pathology slides make a difference to the patient. This study does not address that question.
The cases where DCIS was missed by the outside pathologist may represent a lower risk, harder to detect subset of DCIS. These untreated women will continue to be screened, which may subsequently identify DCIS. In the cases where DCIS was falsely identified by the outside pathologist, the subsequent resection will allow closer examination of the tissue, and allow a definitive diagnosis.
As we seek to control the growth in health care costs we must ask ourselves whether increased diagnostic testing and treatment actually make a difference to the patient.
48
It certainly made a difference to me: not only did I get mutilated on account of a pathologist 'who couldn't really tell", but I got irradiated with dire effect on my left ventricule anterior wall, leaving it with only colateral circulation, and my subclavian artery which had to be bypassed to keep my arm moving. Get real: do you wish this on every woman?
35
As a patient, I think it does make a difference. Detection error on the part of a less-experienced pathologist is a concern. When I was diagnosed with high-grade DCIS, I was told that 10 pathologists could feasibly come up with 10 different diagnoses. This is concerning. A true diagnosis exists, so hospitals should make every effort to increase the accuracy and reduce the variability in pathology interpretation.
6
I take really good care of myself, do everything I am supposed to do: exercise, low weight, lots of vegetables, etc. And I stay as far away from doctors as possible, and if not, second guess them like crazy. I am building a house right now, and at 65, I am on purpose waiting on a scheduled mammogram until the end of the year. Because I know that even if they find something, it's most likely not a crisis. I will get 10 different opinions, and I need to get the dang house finished first. Except for a few scattered obvious UTI's that needed quick antibiotic attention, I can think of nothing in my 65 years that my body would not have healed on its own -- and others where the doctor never gave me a for sure answer. It either resolved, or I figured it out myself. For the most part, doctors are unnecessary if you live a healthy lifestyle. I said for the most part, not always!
3
This article very indirectly supports the view that doctors not be paid by the procedure. The focus should be on the quality of work and the well being of the patient.
If a second biopsy is required it should be because it is in the best interest of the patient, and similarly if surgery seems necessary. It isn't possible for the patient, the patients family or the insurance company to know the degree to which additional income colors either consciously or unconsciously a physician's recommendation.
If a second biopsy is required it should be because it is in the best interest of the patient, and similarly if surgery seems necessary. It isn't possible for the patient, the patients family or the insurance company to know the degree to which additional income colors either consciously or unconsciously a physician's recommendation.
7
When I had a mammogram five years ago, I was told that classifications had been found and I needed a biopsy. I wish then that I'd known about BI-RADs, a way of classifying mammograms. I had the biopsy and the pathology report said "atypical hyperplasica" but there was no more information. By this time, I'd found that my BI-RAD score was 4-a (low suspicion of being cancer). I found out which hospitals had experience with this diagnosis which my insurance would cover to get a second opinion. I had my slides sent to Vanderbilt and the results came back that there was hyperplasia, but no atypia. I wish now I'd been better informed about the low possibility of cancer to begin with and gotten a second opinion before the biopsy.
9
So glad your tests did not indicate cancer. That's the good news. But I find it worrying that all the onus is on the patient to track down diagnostic options on to know about things like BI-RAD, etc. More power to you that you did. I don't think most patients do, and many wouldn't know what to do with that info if they had it. Why isn't this something we expect of doctors? Shouldn't part of patient care be patient education?
12
Thank you for writing this. I'm filing it away in my head in the "just in case I get breast cancer someday" file because this kind of info is not usually given to patients. I've read that you should ALWAYS insist on getting a copy of any mammograms or X-rays done so that if they contain info that's different from or in addition to info your doctor relayed with the results, you'll know and at least be able to do your own research, too. Your comment is a good reminder.
2
Counseling equanimity is easy when you are not faced with a terrifying lump or even a slightly abnormal path report. While we all seek clarity and simplicity, breast cancers are becoming more complex with every new study (immune, genetic, molecular, growth, micro and macro environmental factors, insulin and other signaling pathways, heat shock proteins, drug resistance, etc ).
No matter how many opinions are sought, the inconvenient truth is that really no one knows whether and how a few suspicious cells will change and/or multiply. So every single woman should seek at least one other opinion (preferably more) before making decisions, in addition to seeking information from highly reputable sites.
Breast cancer is now diagnosed in 1 in 8 American women. In my women's group of 20, there are currently 5 with a BC diagnosis, plus one already dead. Can’t we at this point stop calling it one disease, stop pretending a march or pink ribbon contributes anything, stop looking for a one-size-fits-all diagnostic protocol, and stop seeing oncologists who claim expertise in all types of cancer.
Rather, let’s finally have serious public and professional discussion about prevention, highly specialized and individualized treatment interventions, and the shameful inadequacy of public research funding (less than that for eye or blood diseases, less than a third of that for HIV). Can’t we give it at least the public attention devoted to, say, erectile dysfunction?
No matter how many opinions are sought, the inconvenient truth is that really no one knows whether and how a few suspicious cells will change and/or multiply. So every single woman should seek at least one other opinion (preferably more) before making decisions, in addition to seeking information from highly reputable sites.
Breast cancer is now diagnosed in 1 in 8 American women. In my women's group of 20, there are currently 5 with a BC diagnosis, plus one already dead. Can’t we at this point stop calling it one disease, stop pretending a march or pink ribbon contributes anything, stop looking for a one-size-fits-all diagnostic protocol, and stop seeing oncologists who claim expertise in all types of cancer.
Rather, let’s finally have serious public and professional discussion about prevention, highly specialized and individualized treatment interventions, and the shameful inadequacy of public research funding (less than that for eye or blood diseases, less than a third of that for HIV). Can’t we give it at least the public attention devoted to, say, erectile dysfunction?
52
Cancer is a huge industry. Constant radio and tv and print ads for the newest cancer center or drug. Thoughtful diagnoses are out the window for money paid for all the tests. Women are driven into a frenzy by the cancer industrial complex that the slightest abnormality requires at a minimum one mastectomy and harmful chemo and radiation and at the extreme, removal of both breasts and female organs. WHICH insurance pays for. Which I pay for in my premiums and tax dollars.
4
Bravo! What she said! My blood boils every time I see one of those pink ribbons!
6
Agreed. Research estimates for 1000 women screened by mammogram for 10 years, 1 life is saved and 5-15 others "treated" for something that never would have caused a health problem. Women need to be better informed so they can assess their own risk, look at the risk/benefit of mammogram/biopsy, and decide accordingly.
6
Second opinions save lives --- it happened to me in 2009 when my initial DCIS diagnosis was "corrected" to the diagnosis of invasive cancer after secondary review by the brilliant pathologist Dr. Michael Lagios (in San Francisco). I was lucky --- even though his report meant I had to go through a 2nd surgery, followed by chemo and radiation. I'm now six years cancer-free and supremely grateful. A cautionary tale with a happy ending....
17
But you could have also been six years cancer free without any treatment, because you never have had the illness in the first place. That is my impression of the study. Physicians can be pushed by their malpractice insurance companies to recommend unnecessary and expensive treatments "just in case", and for-profit centers are more than happy to provide such services.
It is the for-profit aspect of health care that causes this dilemma. I con't trust my doctor to act in my best interest if it is directly opposed to his or her financial well being.
It is the for-profit aspect of health care that causes this dilemma. I con't trust my doctor to act in my best interest if it is directly opposed to his or her financial well being.
1
I have not, nor any other physician I know of, been contacted by their malpractice insurance company to recommend un-necessary tests. The most contact we (hopefully) have with them is the annual bill.
1
My second opinion (leading to 2nd surgery) revealed that I had a positive sentinel node, meaning the cancer had already begun to spread into my lymphatic system. In other words, my surgeon and initial pathology report were wrong; I did NOT have DCIS but did have invasive cancer. It seems unmistakably clear that had I gone without treatment (and without that additional surgery) I would not only have made it through six years cancer-free, but would very possibly have died from the disease by now.
5
As an oncologist and scientist, I wanted to point out that these types of studies are fundamental to our advancement of medical science. They are neither easy nor glamorous. They frequently lack the cachet of studies testing new therapeutics. However, it is essential that we know the sensitivity and specificity of our diagnostic tests and that we constantly pressure test our gold standards. I hope that these findings will incentive us to fold in new genomic and proteomic technologies into the evaluation of biopsy specimens and move beyond traditional microscopic examination of the tissue. Kudos to the authors for their hard work.
65
I wonder whether the power of modern software would enable a really reliable (and quick) diagnose of scans with data based on thousands of actual cases?
2
Software is modeled on the way that humans do things. Medicine is still much art and not as much science as you might think. Especially when it comes to the very difficult diagnosis of ADH. Molecular pathology is probably the answer in the long term. That is many years off.
3
Having worked as an Onc RN at a major academic teaching center, I am well aware of diverging opinions of the experts and how much outcome can vary, depending on the leading care provider and who's data she trust, from the lab to the pathologist.
Conservative treatment, the so called watch and wait approach, is forced on many woman who do not have metastatic disease. The woman with breast cancer is advised to schlep to a major cancer center every 6 months for expensive tests and monitoring, for years. Related xpense and travel be damned. Many will have to take medication with very serious side effects.
Attempting to catch a micro met the instant it evolves from in situ is a pretty pretty pretty big gamble.
This is why I chose a bilateral mastectomy for what one pathologist called atypica and another called LCIS along with two other breast cancer types, determined to show particular aggression as per his expertise.
Support a woman's right to choose...mastectomy.
Conservative treatment, the so called watch and wait approach, is forced on many woman who do not have metastatic disease. The woman with breast cancer is advised to schlep to a major cancer center every 6 months for expensive tests and monitoring, for years. Related xpense and travel be damned. Many will have to take medication with very serious side effects.
Attempting to catch a micro met the instant it evolves from in situ is a pretty pretty pretty big gamble.
This is why I chose a bilateral mastectomy for what one pathologist called atypica and another called LCIS along with two other breast cancer types, determined to show particular aggression as per his expertise.
Support a woman's right to choose...mastectomy.
17
I completely agree with you that women should be free to choose mastectomy. I had a preventive mastectomy, over 20 years ago due to strong family history, and emotional exhaustion from multiple biopsies. Best decision I ever made!! I can barely describe how free I feel! I know everyone is different, but I have no residual body image issues or discomfort; in fact I have way less discomfort now, and can run with joy like the 11 year old I used to be, prior to developing lumpy, painful breasts. But I had to fight like crazy to get that surgery. The well informed patient should have a strong voice in treatment.
1
I'm curious why pathology isn't done by computer. You'd think it would be more efficient and accurate.
1
Exactly the opposite, actually...there is an infinite amount of histologic variability and subtlety which even the most powerful and advanced computer could never process as well as an experienced pathologist can.
11
It's like a CBC - it's usually done on the machine, but the machine can't differentiate between cells that look very similar but aren't the same. So we have the lab tech do a "manual" differential, which means they look at a slide with a microscope. Still not foolproof, but much more accurate when needed (as with newborns).
2
My personal story showcases a local lab and surgeon who had their own doubts and sent the slides on to Stanford which confirmed the DCIS diagnosis. I am happy to have had my lumpectomy and radiation therapy and five years of Raloxifene.
My bet is that the vast majority of women in my position are happy to have had their chance for treatment and feel better about their present status. I am tired of the media giving such a high profile to the whiners and fearful. Let the ones who want perfect dimple free breasts opt out and stop giving their fears a forum.
My bet is that the vast majority of women in my position are happy to have had their chance for treatment and feel better about their present status. I am tired of the media giving such a high profile to the whiners and fearful. Let the ones who want perfect dimple free breasts opt out and stop giving their fears a forum.
14
I have had more breast biopsies than I can count; upwards of 15. Each has come back normal. For some reason I create a lot of scar tissue, which is now the reason for most of my biopsies. I wish my doctors had not been so quick to cut.....
9
The "CURE" is all I hear about. I want to hear about the "CAUSE". We can land on a comet for god sakes, don't tell me we can't detail some of the causes and recommend the removal of these poisons in our environment. Plastics and a myriad of chemicals are found in these diseased tissues and we never hear a thing about the methodical removal of such culprits. The "CURE" makes money and the "CAUSE" costs money.
For all of our CURE walks and yogurt labels we make gains only in finding the disease, getting more women into the medievil system and resigned to Breast Cancer. Women should demand the medical proffesionals talk as much about what CAUSES this disease, corporate interests be damned!
For all of our CURE walks and yogurt labels we make gains only in finding the disease, getting more women into the medievil system and resigned to Breast Cancer. Women should demand the medical proffesionals talk as much about what CAUSES this disease, corporate interests be damned!
36
Cells that divide frequently make mistakes, it is not always a corporation's fault that we get sick. We know what causes most lung, esophageal, mouth cancers but do we stop smoking?
5
She's talking about the dozens of synthetic chemicals that can be found in peoples' blood and urine, the vast majority of which have not been carefully tested but are somehow "generally recognized as safe." Look at the inappropriate level of influence the chemical industries have over the EPA and the FDA: There are hundreds if not thousands of research papers showing the estrogenic activity of bis-phenol A (BPA) but getting it banned from our plastics has been a steep uphill battle against multinational corporations determined to keep it in use.
They basically use the 'Merchants of Doubt' approach, that nothing is 100% proven so we should just keep on with business as usual. And the more the anti-science republicans take over control of congressional committees to protect their corporate donors, the worse this stands to become.
We live in a virtual sea of toxic chemicals but are reassured over and over that there's nothing to worry about because their levels are so low. Yet that's exactly the level at which most hormones and other signaling molecules work at: very, very low.
On top of that, if and when compounds are in fact tested, they are looked at IN ISOLATION - as if that compound is the only synthetic one is ever going to be exposed to. The possible synergy between these compounds is not being addressed in the least!
Please see: Theo Colburn, Our Stolen Future. We're all being slowly poisoned and it's all "legal." This is nothing short of an outrage.
They basically use the 'Merchants of Doubt' approach, that nothing is 100% proven so we should just keep on with business as usual. And the more the anti-science republicans take over control of congressional committees to protect their corporate donors, the worse this stands to become.
We live in a virtual sea of toxic chemicals but are reassured over and over that there's nothing to worry about because their levels are so low. Yet that's exactly the level at which most hormones and other signaling molecules work at: very, very low.
On top of that, if and when compounds are in fact tested, they are looked at IN ISOLATION - as if that compound is the only synthetic one is ever going to be exposed to. The possible synergy between these compounds is not being addressed in the least!
Please see: Theo Colburn, Our Stolen Future. We're all being slowly poisoned and it's all "legal." This is nothing short of an outrage.
4
when it's you, you want to hear the word "cure"
1
As a pathologist (I participated in the study) I think the grey zone diagnoses should be by consensus. However, when the article claims that pathologists missed the DCIS cases, what this means is that most of these cases were called atypical. We do not have good criteria for called atypical hyperplasia. Experts can overcall and undercall these diagnoses as well. More important, these atypical hyperplasia cases are probably overtreated. These cases are not cancers and probably will not be upgraded to cancer if removed entirely. MRI imaging is probably a better way to follow these women.
18
I went in with a 1 cm lump. "Just a fibroadenoma; come back in 3 months for a re-check." Well! 6 weeks later it was 9 cm. After 20 films and an ultrasound, the radiologist couldn't find anything (???) but "had a bad feeling about this." Ya think!? So off I went to the teaching hospital for a fine needle aspiration. Inconclusive. Then a core needle biopsy, still inconclusive, and the damn thing was still growing. Finally an incisional biopsy and a diagnosis of DCIS. Excuse me??? All the while I was screaming "Get the damn thing out of me and figure out malignancy later." When they did finally take it out, it was 20 cm (yes, really) and stage 3B. Screw doubt and anxiety and aesthetics; these are people's lives we're talking about.
43
As a pathologist with a master's degree in public health specializing in radiation protection and health, I am not convinced that the increased incidence of DCIS and breast cancer diagnosis based on DCIS (whether invasive or never) is not due cellular level changes due to the mammography. It is is well demonstrated that high dose x ray studies (see Alice Stewart) will cause cancer; what is not well demonstrated is the impact of very low dose ionizing radiation at the cellular level; ionizing radiation that is focused directly at a breast that has its density increased by compression, which increased linear energy transfer (imagine taking x rays of cells). The increased use of mammography might very well be the self fulfilling prophecy of an increased incidence of DCIS (that never becomes invasive (60% of the time)).
45
You're not the only one pointing this out, either! I read somewhere that if you get an annual mammogram every year starting at 40, by the time you're 70 each breast (or maybe both together?) has been exposed to JUST SHORT of the radiation that people absorbed at Nagasaki. And we know that radiation damage is cumulative. Now, maybe that was before digital mammograms, which I guess use less radiation. But that definitely can't be good. And apparently people with the genetic predisposition to breast cancer (I forget which gene this study involved) who started mammograms at 30 (as used to be recommended for this group) got breast cancer at higher rates than those with that genetic issue who didn't get the mammograms! Plus I think there's some evidence that the compression from the mammograms sometimes helps DCIS to spread because it breaks the encapsulation on the duct and makes the stuff escape that. There's definitely reason for caution here.
2
Actually, you are wrong about radiation damage being cumulative. It is not. Radiation damage either occurs or it does not. Think of it like playing the lottery week after week. Your odds of winning are the same this week as they were last week. Radiation damage is the same. The chance of inducing a cancer with a given radiation dose is the same for each exposure given as long as there is enough time between exposures fo the DNA repair mechanisms in each cell to do their job - on the order of a few hours.
2
Ionizing radiation induces cellular damage based on linear energy transfer which is dependent on the density of material that it passes through; radiation damage may not be itself directly cancer producing; it does increase cellular free radical formation which can and does damage cellular organelles. In some cases, the damage is so great that the damage kills the cells; in others, its enough to result in living but abnormal cells. Factoring in the two hit hypotheses, a second does of radiation could induce even more damage. whether it is one hit or two hit, ionizing radiation could be enough to inhibit normal DNA repair mechanisms or genetic loci responsible for cancer mutation inhibition such as P53
2
Get a second (or more) opinion!! Best medical advice there is.
5
As one who had the results "atypia"- I was herded along to biopsy, surgical biopsy, and aromatase inhibitors, with a suggestion of semi annual MRIs. After my PCP received final reports and questioned these invasive steps I received a second opinion from another breast cancer specialist (it's Boston-- local experts are pretty darn good). Her recommendations were quite less invasive, more toward careful monitoring. As the months and many appointments went on, I learned better how to listen and extract the needed information.
Doctors don't always explain well. If you see three doctors, even if they are clear, they explain differently than their colleagues even when in agreement. I now close each and every doctor appointment with this line: "This is what I heard you say. [repeat what I heard] Is that correct? Please re-explain any part that I misunderstood in language that a lay person can understand." I will do this as many times as it takes (one time it was three tries--Doc was exasperated, clearly thought I was an idiot, but she was ridiculously unclear) until I'm sure I understand. I also take notes. So advice from a patient: Listen carefully, ask and ask again, don't leave until you understand, ad take notes. .
Doctors don't always explain well. If you see three doctors, even if they are clear, they explain differently than their colleagues even when in agreement. I now close each and every doctor appointment with this line: "This is what I heard you say. [repeat what I heard] Is that correct? Please re-explain any part that I misunderstood in language that a lay person can understand." I will do this as many times as it takes (one time it was three tries--Doc was exasperated, clearly thought I was an idiot, but she was ridiculously unclear) until I'm sure I understand. I also take notes. So advice from a patient: Listen carefully, ask and ask again, don't leave until you understand, ad take notes. .
56
Pathology is a specialty of interpretation. Often times "experts" disagree about subtle difference although rarely about substantive diagnoses. It is a human endeavor so this should not be surprising.
10
"experts rarely disagree about substantive diagnoses"
And you say with such utter certainty because?
And you say with such utter certainty because?
1
In 1887 the crown prince of Germany, Frederick, was discovered to have a small growth on his vocal cord. His initial doctors said it was malignant, but the English Doctor Rudolf Virchow, the "god of Pathology" as one modern pathologist has called him, called it benign. In fact, Frederick had cancer of the larynx and died in 1888, putting Wilhelm II on the throne. One missed diagnosis may have helped instigate WWI... the experts aren't always right.
8
Bill can say that with utter certainly because decades of research and data collection shows that, in fact, experts usually agree. They all work from the same database and honed the same skills.
If a biopsy is positive and the breast is removed, the pathology on the surgical specimen will show no cancer. If the biopsy is false negative, the mistake will appear when the disease advances. In either case, biopsies and follow ups are reviewed at regular, frequent interdisciplinary conferences where surgeons, pathologists, and others discuss each case and its follow up. Errors are quickly detected by the team. An "expert" who makes a lot of mistakes quickly loses his job.
I am a specialist in internal medicine.
If a biopsy is positive and the breast is removed, the pathology on the surgical specimen will show no cancer. If the biopsy is false negative, the mistake will appear when the disease advances. In either case, biopsies and follow ups are reviewed at regular, frequent interdisciplinary conferences where surgeons, pathologists, and others discuss each case and its follow up. Errors are quickly detected by the team. An "expert" who makes a lot of mistakes quickly loses his job.
I am a specialist in internal medicine.
6
I am a layperson, not a doctor or scientist. My wife has had several lumps appear in her breasts over the years and had biopsies or removal in each case. In every case it was benign fatty tissue. But we don't care. We follow the principle of "if in doubt, take it out". It disturbs us greatly that there are those who worry about unnecessary procedures. Their vision is hindsight. She was once told that a spot in her lung were nothing and that additional x-rays could increase her risks. Against her doctor's advice she had a biopsy taken, cancer was found and her left top lobe removed. Another time she had an anal lump which went undiagnosed for years until a medical assistant insisted that a surgeon take a biopsy. Result - anal cancer and radiation treatment. She is now 5-years out on both, thank God. The moral of this tale - their statistics, her life.
64
You sorta dont get it: she had biopsies and you say they found real cancer. But was it actually cancer or a misreading of the biopsy? You seem to understand that these tests are not conclusive but then you say they are.
And there's the other central issue of having invasive procedures and risking hospital-based infections because it is "better to be safe." Please dont think invasive surgery is not a risk. It is just a different kind of risk.
And there's the other central issue of having invasive procedures and risking hospital-based infections because it is "better to be safe." Please dont think invasive surgery is not a risk. It is just a different kind of risk.
37
I'm a layperson, too. I have a friend with terminal breast cancer, so I can see the advantages to "if in doubt, take it out."
But over the last 10 years or so I've had multiple call-backs after preventative mammograms. I've had further diagnostic mammograms, sonograms, and a couple of biopsies. No medical problems have ever been found, but I've paid thousands of dollars out of pocket to cover the costs. Now they want me to have mammograms every 6 months, even though they didn't find anything last time (while charging me nearly $500, beyond insurance, for looking).
I work at a university and have decent health insurance, but it doesn't cover the full cost of these procedures.
I have this sneaking suspicion that I keep getting referrals for diagnostic mammograms and so on just because they want to increase profits under the guise of playing it safe.
But over the last 10 years or so I've had multiple call-backs after preventative mammograms. I've had further diagnostic mammograms, sonograms, and a couple of biopsies. No medical problems have ever been found, but I've paid thousands of dollars out of pocket to cover the costs. Now they want me to have mammograms every 6 months, even though they didn't find anything last time (while charging me nearly $500, beyond insurance, for looking).
I work at a university and have decent health insurance, but it doesn't cover the full cost of these procedures.
I have this sneaking suspicion that I keep getting referrals for diagnostic mammograms and so on just because they want to increase profits under the guise of playing it safe.
13
You sorta don't get my point. She would rather risk hospital infections and invasive surgery than play Russian roulette with a silent killer like cancer, If you want to do that, your choice and good luck to you.
3
As a patient with DCIS who went for a lumpectomy, I have a very short temper with the people who complain about additional anxiety, and go for a "wait-and-see" protocol instead. The whole point, it seems to me, is to remove the cell groups when they are small and BEFORE they become invasive, if possible. That is when the statistics for a return episode fall into the low single digits. This is NOT something where you can throw the dice and say there's no way to tell what is going on. The article is great in that it highlights the need for more accurate testing, but when it starts talking about how DCIS is not really cancer, I think you are really endangering people's lives. The word in there is "carcinoma," after all. What is overlooked is the resistance that many women have to any kind of breast disfigurement, especially on a first diagnosis. I later had a completely unrelated breast cancer requiring a mastectomy, and I cannot tell you how many women I have asked, "Do you want to die?" when they come for advice on a more invasive diagnosis, saying, "but I can't lose my breast." It's a non-vital body part like any other, but fraught, unfortunately, with all kinds of cultural esteem and definitions of femininity. Even when the solution is as undetectable as a lumpectomy, first experiences with breast cancer carry what I consider irrational fears and need to be countered, not reinforced. This article emphasizes an interpretation that is not helpful.
37
Not everyone who wants to keep their breasts whole is responding to cultural ideas about femininity or concerned with body image.
For some, the physical sensitivity of their breasts is a huge part of sex/orgasm. Living without that (especially unnecessarily) would be a profound sensual loss, not a blow to vanity.
For some, the physical sensitivity of their breasts is a huge part of sex/orgasm. Living without that (especially unnecessarily) would be a profound sensual loss, not a blow to vanity.
12
Right on! I just posted! Take the breasts off the pedestal! Stage one, tiny dcis- I had eveything off and coukd not be happier..
1
As a breast cancer survivor and as one who as had a double mastectomy, you are not offering advice to these women but are scaring them. Advice should be based in science and not fear. So you need to rethink your fear tactics. They are based in your emotions.
8
"In the United States, about 1.6 million women a year have breast biopsies; only about 20 percent of the tests find cancer .... About 60,000 women each year are found to have ductal carcinoma in situ, or D.C.I.S., which also refers to abnormal cells that are confined inside the milk ducts and so are not considered invasive ..."
In 2014, I became one of those 60,000 women and my primary care doctor referred me to a breast surgeon. A pre-surgery MRI turned up areas of suspicion in both breasts, missed by the screening and diagnostic mammograms, which led to further biopsies. The left breast was fine; that invasive procedure and the subsequent pain and bruising were for nothing. The right breast, however, had a small amount (4 mm) of invasive cancer, luckily low-grade and not aggressive, with no lymph node involvement. I had a lumpectomy and will soon start radiation therapy.
If I hadn't been sent for treatment for the DCIS, my cancer might not have been found until it was well past Stage 1. Given the many gray areas and ambiguities surrounding diagnoses of early-stage breast cancer and "pre-cancers,", I'm inclined to favor overtreatment, including those possibly unnecessary biopsies.
In 2014, I became one of those 60,000 women and my primary care doctor referred me to a breast surgeon. A pre-surgery MRI turned up areas of suspicion in both breasts, missed by the screening and diagnostic mammograms, which led to further biopsies. The left breast was fine; that invasive procedure and the subsequent pain and bruising were for nothing. The right breast, however, had a small amount (4 mm) of invasive cancer, luckily low-grade and not aggressive, with no lymph node involvement. I had a lumpectomy and will soon start radiation therapy.
If I hadn't been sent for treatment for the DCIS, my cancer might not have been found until it was well past Stage 1. Given the many gray areas and ambiguities surrounding diagnoses of early-stage breast cancer and "pre-cancers,", I'm inclined to favor overtreatment, including those possibly unnecessary biopsies.
18
And it could very well be you are in the group of "overtreated" for something that would never have progressed and caused health concern. My point is that doctors need to do a better job of educating women so they can make the choice best for them.
3
That is the problem with breast MRI. It is highly sensitive, but not very specific. However, you did the right thing by getting treated. Letting an invasive Cancer go is not a good thing, regardless of how aggressive it is.
2
I find this story very similar to the uncertainties faced by men who have prostate biopsies with indeterminant results. Variable biopsy interpretations (i.e., the Gleason Score) followed by a bewildering number of treatment options whether faced with BPH or cancer, often result in a great deal of stress and uncertainty. Personally, I do not care for the typical advice, "Talk with your doctor to find out what is best way to proceed for you."
I hope that anyone in this situation can at least get access the best possible specialists. Poor biopsy readings lead to bad treatment decisions.
I hope that anyone in this situation can at least get access the best possible specialists. Poor biopsy readings lead to bad treatment decisions.
8
I hear you. It struck me (as I now wait for my biopsy results for prostate cancer) that we've got ourselves into a heck of a pickle because we have a very difficult time figuring out which cancers kill and which merely drive us insane. While I know as sure as I still breathe that we are a society of over treatment and over regard for the medical community, we are also saving some lives. And it seems there is no certainty moving forward as to how to proceed at this moment in history.
7
The writer and the experts seem to be certain that the 2 experts reviewing the biopsies are 100% correct in their diagnosis. For some reason no one has mentioned the possibility that the other physicians reading the biopsies may be correct and the so called experts wrong. In any event this should not surprise anyone. Physicians whether they are experts or not make many many errors. It is part of being human. It is the patients responsibility and duty to always have a serious diagnosis confirmed by at the very minimum 2 physicians and preferably 3.
15
Breast pathology is very, very difficult and the terminology and diagnoses change often, especially in borderline/atypical lesions. Furthermore there is sometimes a difference in the grade of the cancer from one breast pathologist to another.
As a former academic pathologist it has become imperative to have one's needle biopsies and excisions read by a pathologist at a major academic center and one who specializes in the field. I have seen too many referral cases where lesions are often misdiagnosed or missed altogether.
I realize that access to these centers is difficult for many women, and yes, men, but they can be sent out for a second opinion. Don't let the surgeon/obgyn discourage you. Send it out.
As a former academic pathologist it has become imperative to have one's needle biopsies and excisions read by a pathologist at a major academic center and one who specializes in the field. I have seen too many referral cases where lesions are often misdiagnosed or missed altogether.
I realize that access to these centers is difficult for many women, and yes, men, but they can be sent out for a second opinion. Don't let the surgeon/obgyn discourage you. Send it out.
79
I agree there is value to sending pathologic slides out for second opinions, but there out expert pathologists outside of "major academic medical centers," and there are not many large centers in many of the midwest states. A better suggestion is to have the slides reviewed by pathologists at facilities designated by the National Accreditation Program for Breast Centers through the American College of Surgeons.
7
To the extent that interpreting prostate biopsies have similar challenges to breast biopsies, I couldn't agree more. I know of examples where prostate biopsy interpretations were substantially different between the local pathology lab and a major world-class academic institution which of course leads to very different treatments.
2
Yes, breast pathology is difficult. No, the only expertise is not in academic medical centers. this is a view generally held by those in, well, academic medical centers, where there is a certain amount of bias.
I practiced in both major medical centers and the community. Rare and particularly difficult diseases certainly belong there. There is plenty of expertise, quality assurance, and external review in the community for common diseases. I regret of say that breast cancer is one of these.
I will be happy to learn if recurrence rates for uncomplicated breast cancer are better in academic centers than in community hospitals. I am not aware of data to show this.
I practiced in both major medical centers and the community. Rare and particularly difficult diseases certainly belong there. There is plenty of expertise, quality assurance, and external review in the community for common diseases. I regret of say that breast cancer is one of these.
I will be happy to learn if recurrence rates for uncomplicated breast cancer are better in academic centers than in community hospitals. I am not aware of data to show this.
4
3-D or Tomogram Mammography should result in greater sensitivity for cancer and more specificity = fewer biopsies in the first place.
This could well be the development that will both reduce the number of breast biopsies and increase the percentage of biopsies showing cancer.
This could well be the development that will both reduce the number of breast biopsies and increase the percentage of biopsies showing cancer.
5
According to the JAMA study, the three reference pathologists agreed unanimously on the diagnosis for only 75% (180 of 240) of the cases initially, with 25% resolved after consensus discussion. This is how pathologists work in real-life circumstances. The study did not allow the 115 pathologists to discuss/consult with colleagues. Thus, the study findings do not reflect the reality regarding the accuracy of the pathologic diagnosis of breast biopsies.
70
Agree. The study increased the likelihood of disagreement, but otherwise demonstrates that uncertainty exists and must be investigated and discussed with the patient.
7
Bingo!
An elementary design flaw that ought to have been corrected before considering publication. The control groups were treated differently. There were two options offered. The three-person expert group was treated as consensual (2-1 wins); the other group was non-consensual (66%-33%), so one sub-set "disagreed" with the final expert consensus, even if the vote was identical.
An elementary design flaw that ought to have been corrected before considering publication. The control groups were treated differently. There were two options offered. The three-person expert group was treated as consensual (2-1 wins); the other group was non-consensual (66%-33%), so one sub-set "disagreed" with the final expert consensus, even if the vote was identical.
5
This article is somewhat misleading in comparing the readings of individual pathologists with a consensus read by three pathologists. The individual readings by the three experts diverged significantly from their own consensus. As you say, this piece as well as the JAMA article misleadingly portrays the community pathologists and the experts as differing significantly in their assessments of the slides but in truth the performance on an individual basis was similar.
If one is to have the most accurate results, the lesson to take from this study is to have multiple pathologists look each set of slides and then discuss their findings to come to a consensus opinion.
When it comes to the practice of medicine, the NYT is much better at raising an alarm than at soberly analyzing the medical literature.
Also, when they (the NYT) can conclude that health care is bad outside the Ivory Towers and bad in flyover country, they will break their arms patting themselves on the bad to crow about it.
If one is to have the most accurate results, the lesson to take from this study is to have multiple pathologists look each set of slides and then discuss their findings to come to a consensus opinion.
When it comes to the practice of medicine, the NYT is much better at raising an alarm than at soberly analyzing the medical literature.
Also, when they (the NYT) can conclude that health care is bad outside the Ivory Towers and bad in flyover country, they will break their arms patting themselves on the bad to crow about it.
5
It can be confusing and frustrating but we have come so far in such a short time with better understanding of breast cancer, methods of diagnosis and determining the proper treatment. There is still so much to learn and a long way to go as we discover more about not only breast cancer but cancer in general. We don't have a perfect solution and maybe we never will.
Still I am happy to be a person who was treated for breast cancer today than not that many years ago.
Still I am happy to be a person who was treated for breast cancer today than not that many years ago.
7
As an obstetrician-gynecologist, I see about 20 or 30 women in clinic each weekday. A large number of my patients who are 45 or older report a history of "breast cancer", but when I look up their pathology, it is DCIS (ductal carcinoma in situ) much more often than invasive cancer. Many women choose mastectomy to treat this lesion.
The JAMA study is fascinating and well-done, but a bunch of second opinions will not help if women are convinced that every atypical cell is an invasive cancer. Once you have bought the pink shirt and walked in the walkathon, you have rushed the breast cancer sorority.
Luckily, most women with precancer of the breast will have a good outcome and live many productive years after their treatment.
The JAMA study is fascinating and well-done, but a bunch of second opinions will not help if women are convinced that every atypical cell is an invasive cancer. Once you have bought the pink shirt and walked in the walkathon, you have rushed the breast cancer sorority.
Luckily, most women with precancer of the breast will have a good outcome and live many productive years after their treatment.
117
One of our friends could not get health insurance (pre ACA) due to such a diagnosis. Then one day a doctor told her she did not have cancer and never did.
44
Maria - believe me I did not drink the pink juice when I was DX with DCIS. I fought my doctors (more than 1) that their treatment plan was overkill. They were adamant that this was the "standard of care". Yeah, now I can look back and see that I should have followed my head/heart, but there you go, hindsight. It's 10 years later for me and it burns me that they still don't know what they're doing. The problem is we have a breast cancer industry; not the women want to join the club.
16
Our quest for perfection and desire to to eliminate uncertainty leads to more tests, more second opinions and more anxiety. Not every specialist can be the ultimate expert in his field. I would suggest a more conservative general approach and an effort to maintain equanimity in the face of challanges.
RLS Radiologist
RLS Radiologist
17
I had a lump in one breast 28 years ago and after a thin-needle biopsy I was told that I had a 27% chance of getting breasr cancer. I decided I could live with that; my parents, however, nagged me until, two years later, I had it removed. Completely benign. Fast forward 14 years to a lump in the other breast. No biopsy. Today, 16 years later, I am still alive, very healthy, still witg lump in my breast. No mammogram in 16 years.
48
Oh please, have your mammogram!
30
Head in the sand is not a good alternative.
20
Once in a while you may win the jackpot. You can't rely on that to build your life.
Have a mammogram; if you're still lucky it will be normal, if not you'll have a treatment sooner (and better).
MD, FACS
Have a mammogram; if you're still lucky it will be normal, if not you'll have a treatment sooner (and better).
MD, FACS
12
As a retired general surgeon, and special interest and practice in patients with breast abnormalities, D.C.I.S. continues to humble us, as we have, in general, recommended definitive surgery (likely a wide excision or partial mastectomy), with radiation, to minimize local recurrence if the pathologist suspects the probability of progression to invasive cancer in the future. This remains a gray zone but with a tendency towards conservatism, provided patient's approval and a professional team willing to remain on the alert. Insofar biopsy is concerned, it may be deemed very reasonable to repeat it if there is any concern of an incomplete sampling (usually an x-ray or ultrasound-guided needle biopsy by a radiologist, or, combined with an open biopsy by a surgeon. The difficulty, as I see it, is a mammographic image possibly representing a malignancy, and just following without a biopsy (ever heard of our litigious nature?). Women must be assured we continue to have their interests...and health, as our ultimate goal. And this, not only by continuing our education but the dedication requires by our chosen 'calling'. I mention this, as Health Care is big business, and patients may fall through the cracks if personalized care is lacking. Even in the case of a humble breast biopsy.
7
The entire field of breast cancer screening, diagnosis and treatment currently seems to be a morass of confusion and conflicting professional opinion. The advice given to women is frequently contradictory, baffling and/or incomprehensible. It is a frightening mess.
158
I can't help wondering about the economics behind it. With armies of manufacturers and radiology centers invested in the current equipment and techniques, how much r & d is going into searching for a major leap forward in screening?
14
" It is a frightening mess" because we as a society have abdicated our personal responsibility to live a generally healthy life and in the process become more and more dependent on the professionals, who, of course have less and less time as health keeps becoming more and more expensive for the simple reason that we still do not live in an world where resources are infinitely cheap.
1
Arif.....oh, it's our fault for not living a 'healthy life'? In every single discussion of any disease we get these scolds.
Linda....re the economics, I don't know how much of a factor that is, but we are the country with the most profit driven medicine. A Times article might look at the dozens of other nations with universal, lower cost health care, and see what their situation is if any regarding diagnosis, over testing, over treatment. And do they have the same morass of confusion?
Linda....re the economics, I don't know how much of a factor that is, but we are the country with the most profit driven medicine. A Times article might look at the dozens of other nations with universal, lower cost health care, and see what their situation is if any regarding diagnosis, over testing, over treatment. And do they have the same morass of confusion?
2
We are only now realizing the complexity of all cancers. They all are metabolic abnormalities that take place in each cell, especially the stem cells. This happens simply because we are alive and are cells divide an grow. Each cancer has one or more "drivers', proteins produced by the cells genes that promote the cancer . The cancer can look the same under the microscope but be an entirely different cancer cell mechanism. Even tumors have different drivers (mutations) in the sane tumor. These can be identified and antibodies to block them are being made. This will allow each cancer to be "personalized' and treated. it may even be possible to have blood or even saliva or urine tests that id the abnormal proteins early and the drugs can be given before the cancer can be seen. It is possible vaccines will be made against these proteins that stop them as soon as they are produced.
See letswakeupfolks.blogspot.com-Follow all the cancer pathways and the real cause of cancer for detailed discussion.
See letswakeupfolks.blogspot.com-Follow all the cancer pathways and the real cause of cancer for detailed discussion.
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As an Oncologist I find it very frustrating. We owe our patients some uniformity even if it means getting another Pathology opinion on every biopsy.
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As an oncologist you should also know that not all biopsies are definitive. I have no doubt that you can have the type of findings for colon polyps. Tak the polyp out, and find atypical cells that may be Cancer or may not be. It is the nature of the beast.
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