Challenging the Status Quo in Breast Cancer Screening, Treatment

Breast cancer expert Dr. Laura Esserman questions whether the desire to ‘do something’ drives over-diagnosis, over-treatment.

Are we over-treating some breast cancers, exposing thousands of women to needless anxiety and unnecessary treatments? When breast cancer is diagnosed, do we provide women with the most effective and least harmful treatments as quickly as possible? 

Those are the difficult questions Laura Esserman, MD, MBA, asks as a professor of surgery, clinician-researcher, and director of the Carol Franc Buck Breast Care Center at UCSF

Esserman was one of the first breast cancer experts in the US to argue that invasive breast cancer spans the spectrum from ultra-low risk to very aggressive, so an assessment of each individual’s risk should guide treatment and screening approaches. 

Ductal carcinoma in situ, or DCIS, a pre-cancerous condition confined to the breast ducts, is an important area where Esserman believes better options and less aggressive approaches are needed. Many cases of DCIS will never result in invasive cancer. 

Yet women diagnosed with DCIS are subjected to biopsies, lumpectomies, radiation, and mastectomies. The abnormal cells detected through screening are themselves not life-threatening, so there is less need for urgent interventions and more opportunities to test “doing less” safely, Esserman says. 

Improved screening means that approximately 60,000 cases of DCIS are now being diagnosed annually, but Esserman questions whether the desire to “do something” is driving over-diagnosis and over-treatment. 

Named one of Time magazine’s 100 Most Influential People in 2016, Esserman seeks to improve the value of screening and prevention. In 2015, she started the WISDOM trial, a five-year UC Health system-wide effort with more than 100,000 participants. It’s designed to show that personalized screening and prevention, based on each individual’s comprehensive risk, is as safe and of greater value than annual screening. 

Esserman is also the principal investigator on I-SPY 2, a 16-center nationwide clinical trial intended to expedite the discovery of new drugs – some of which already have been tested on other cancers – or combinations of drugs that dramatically increase the chance of eradicating tumors before surgery. 

I-SPY 2 has produced some extremely promising results. For example, in some patients with triple-negative breast cancer, one of the experimental drugs in the trial, when combined with standard chemotherapy, tripled the chances that their tumors would disappear completely before surgery. 

Laura Esserman is the Alfred A. de Lorimier Professor of General Surgery. 

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