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Thursday, September 03, 2015



This is the sixth in a series of profiles of oncologists discussing how they unwind during the summer -- or other!-- months. Check out the entire series here.  From traveling to music festivals and hidden oases to growing organic gardens and cycling to raise research funds, the profiles show the rich and diverse interests and unique experiences cancer experts have beyond their clinic and lab doors.  You can also follow the tweets about this series here: #OTSummerVaca.


Deanna Attai, MD

When Oncology Times asked breast cancer surgeon Deanna Attai, MD, where she goes to unwind on her summer vacation, she said, "I don't have a summer vacation!"


"The last time I took a real vacation was in 2004. Because I have to travel a lot for work, I don't really take a true summer vacation," says Attai, the President of the American Society of Breast Surgeons and Assistant Clinical Professor in the Department of Surgery at UCLA David Geffen School of Medicine.


Since last January, she's been away from home a week out of every month so she says just being home is nice – especially in her backyard where she grows an organic garden.


"My garden is my therapist and my counselor and my everything," says Attai, adding that she's lucky to live in southern California where the climate allows for almost year-round gardening.


She credits her mom--"a total green thumb when I was growing up"--as one of her inspirations.


"She'd grow African violets and orchids, some blueberry bushes. We had a lot of plants outside. I hated all of it because my sister and I had to do the weeding. Or we'd get dragged to a nursery on the weekend and we'd have to look at plants and we were bored out of our minds," Attai laughs.


She first reconnected with plants as an adult in 2007 and 2008. She was living in a condo at the time and grew herbs on her balcony. In 2009, she bought a house in Burbank, Calif., where the previous owner had kept roses and a few other plants in the backyard.


"I tried planting some vegetables. I didn't know what I was doing. And then the nurses at the hospital told me the pine trees gave a lot of shade and the pine needles were acid. So I called a tree guy and had the tree hauled out and I've pretty much slowly over the last four years been whittling away at the lawn out back, expanding the garden area so that now two-thirds of the backyard is garden and the other third is a narrow lap pool," Attai says, adding that she's learned a lot from trial and error, research, and conversations with other green thumbs.


The fruits of her labor include tomatoes, beans, butternut and acorn squash, sugar pie pumpkins, turnips, garlic, and cucumbers. When the weather turns cooler, she cultivates broccoli, spinach, kale, beets, and this past year, a "puny" crop of sugar snap peas.


"For the past few years I've started everything from seed in January and February inside--all organic heirloom."


What does she do with her bounty? "I give a lot of it away. I gave a bag of tomatoes to the OR staff."


She also has a freezer full of squash from last year, carrots that she's pureed, zucchini brown rice burgers, and tomato sauce.


Her secret to tasty homemade sauce: "I roasted my paste tomatoes with onion and garlic and pureed them with fresh basil, and thyme and oregano I planted last year."


Some of her other favorite herbs include lavender and chamomile that she dries and uses in tea.


Attai says she enjoys sharing her passion for plants with her patients, family, and friends on a Facebook page where she posts lots of colorful photos.


"It's funny. Friends come over to the house and say, 'You should open a farm stand', but I think that would take the fun out of it for me."


Gardening has also enriched her insights about life, she says. "It has made me more... there's definitely a cycle in the garden and not everything does well. I have a huge compost bin and I do a lot of composting and I keep amending the compost. It makes you appreciate life cycles and nature."


And it's just so peaceful, she adds. "I planted a lot of milkweed and now I get a bunch of humming birds. Sitting back there is so peaceful, calming, and tranquil. My dad, a retired cardiac surgeon, would come home in the evenings, back in New York where I grew up, and just go walking around in the garden and I used to ask my mom, 'What is he doing?' and now I do that and I know."


"As a surgeon, I'm orderly and organized and the garden has helped me get out of that. A garden does what it does. Nature does what it does," and she says it's good to be reminded of that.



        Just a few of the many photos on Dr. Attai’s Facebook page


Monday, August 31, 2015



The American Society of Clinical Oncology has issued a new clinical practice guideline on systemic therapy for patients with stage IV non-small cell lung cancer (NSCLC). The new evidence-based guideline updates the NSCLC treatment guideline published in 2009, and succeeds another ASCO document, a “Focused Update” related to switch maintenance, published in 2011


Early initiation of palliative care concurrent with treatment is stressed. ASCO, which has been emphasizing the benefits of concurrent palliative care for several years now, is co-sponsoring (with the American Academy of Hospice and Palliative Medicine, the American Society for Radiation Oncology, and the Multinational Association of Supportive Care in Cancer) the Palliative Care in Oncology Symposium, which will be held October 9 and 10 in Boston. This second annual conference, which has the theme “Patient-Centered Care Across the Cancer Continuum,” will include sessions on communicating with patients about their values and preferences, and having more, earlier, and better goals-of-care conversations with seriously ill cancer patients.


The new guideline for advanced lung cancer, which, the authors note, is based on a review of 73 Phase III randomized controlled trials on systemic therapy and reviews data on afatinib, ceritinib, crizotinib, erlotinib, and continuation and switch maintenance, emphasizes that patient age alone should not be a factor in treatment selection.


A majority (approximately 53%) of new cancers in the U.S. occur among patients age 65 and older who are Medicare patients, according to ASCO data. In 2014 Medicare announced that it would cover routine lung cancer screening for high-risk patients, a decision praised by ASCO and supported by evidence-based guidelines from ASCO and the American College of Chest Physicians.


Histologic and Molecular Subtypes

The release of the new guideline, now online ahead of print in ASCO’s Journal of Clinical Oncology was prompted by an increased understanding of histologic and molecular subtypes of NSCLC, noted the lead author, Gregory A. Masters, MD, Co-Chair of the ASCO Expert Panel that developed the recommendation. Masters, Attending Physician at the Helen F. Graham Cancer Center and Associate Professor at Thomas Jefferson University Medical School.


“Although there is no cure for stage IV non-small cell lung cancer, various treatment options are available that can help patients control their cancer longer,” Masters said in a statement. Based on the biology of the tumor, there are specific treatment recommendations for first-line, maintenance, second-line, and third-line treatment in the new guideline.


Main Recommendations

Key treatment recommendations are as follows:

First-line treatment:

·    If the lung cancer lacks EGFR or ALK gene alterations, combination cytotoxic chemotherapy for patient with performance status 0-1 is recommended;

·    For patients with a performance status of 2, chemotherapy or palliative care alone may be used;

·    If the cancer has sensitizing EGFR mutations, afatinib, erlotinib, or gefitinib is recommended; and

·    If the cancer has ALK or ROS1 gene rearrangements, crizotinib is recommended.


Maintenance treatment (after initial response to first-line treatment):  Patients may be recommended to either switch to another regimen, or continue first-line therapy, or take a break from chemotherapy.


Second-line treatment:

  • Docetaxel, erlotinib or gefitinib are treatment options; pemetrexed is an additional option for patients with nonsquamous cell carcinoma;
  • Patients with EGFR mutations can receive chemotherapy or another EGFR inhibitor, depending on the initial response; and
  • Patients with ALK rearrangements may be offered chemotherapy or ceritinib.

Third-line treatment:  Erlotinib may be offered to patients with a performance status of 0 to 3 who had not previously received erlotinib or gefitinib.


No Longer Includes Cetuximab

The 2009 and 2011 documents included a recommendation that oncologists consider the addition of cetuximab to cisplatin/vinorelbine in first-line therapy for patients with EGFR mutations as measured by immunohistochemistry, based on the FLEX (First-line Treatment of Advanced Non-Small Cell Lung Cancer) clinical trial. Now, though, the new guideline states: “This method of assessing EGFR expression has not been shown to be feasible.”


In addition, cetuximab is not approved for patients with NSCLC, and a trial of cetuximab in addition to taxane plus carboplatin versus taxane plus carboplatin resulted in a shorter progression-free survival with cetuximab, along with some adverse effects. As a result, this recommendation was removed.


Strong Benefit for Early Concurrent Palliative Care

The updated NSCLC guideline makes it clear that when oncologists begin early concurrent palliative care services along with disease-modifying therapy, there is a strong benefit for cancer patients. In a section of the journal article on the value of palliative care, Masters and his coauthors note that in 2012 ASCO reviewed the evidence from a randomized clinical trial that showed an increase in median overall survival for patients receiving palliative care services while also receiving active cancer treatment. The study subjects in that trial had stage IV NSCLC.


Multiple randomized trials have found that cancer patients receiving palliative care show an improvement in symptoms, including less anxiety and depression, higher overall satisfaction, and less caregiver distress, the new guideline notes. “As a community, we need to overcome the perception of the cure/care dichotomy and recognize that palliative care belongs throughout the continuum of care,” the guideline authors emphasize.


Hospice Information Visit

The guideline recommends a hospice information visit when the patient has about six months to live. In addition, “We also suggest specific language, based on well-designed clinical trials, to help with the planned transition to hospice and a specific statement of non-abandonment, such as ‘whatever action we do take and however that develops, we will continue to take good care of you; we will be with you all the way.’”


Such a statement helps to allay fear, anxiety, and depression in patients who may believe that their oncologist is giving up on them. The guideline also notes that there is a stigma associated with lung cancer because of its link to smoking, and this stigma can increase depression and decrease quality of life.


The document also notes that some patients may misunderstand their diagnosis and prognosis and think that their advanced NSCLC is curable. In one cited study, one-third of patients with advanced NSCLC reported that their cancer was curable at baseline, and a majority reported getting rid of all their cancer as a goal of treatment.


Therefore, states the guideline, “A dedicated session with the patient and preferably a caregiver should take place immediately after diagnosis to honestly and completely discuss the diagnosis, treatment (benefits and risks), prognosis, and palliative care concurrent with any anticancer therapy. Physicians should ‘talk with patients about palliative care and end-of-life preferences early on, not in the weeks before death.’”  

Also recommended is that a similar discussion take place before each new therapy is considered, especially third-line and beyond treatment.

Monday, August 31, 2015




The American Society of Clinical Oncology has updated its policy statement on genetic and genomic testing for cancer susceptibility. A key reason for the update was to address the opportunities and challenges of new next-generation sequencing as it applies to cancer screening and cancer treatment decisions, according to the authors of the statement, which is published online ahead of print in the Journal of Clinical Oncology (DOI: 10.1200/JCO.2015.63.0996).


“The availability of broad based next-generation sequencing at affordable prices creates the opportunity to identify a greater proportion of those with increased genetic risk for cancers—and thereby offer them maximal surveillance and prevention options,” explained Noralane M. Lindor, MD, Oncologist and Medical Geneticist at Mayo Clinic who is a member of ASCO’s Prevention Committee that co-developed and co-wrote the updated policy statement with ASCO’s Ethics Committee.


“But with this new technology, there is definitely greater complexity in having conversations with patients about their goals, expectations, and preparing them for the numerous possibilities—helpful results, surprising results, ambiguous results, disappointing results, or no result—which increases the responsibility of the ordering clinician proportionately,” she said in an email.


New Next-Gen Technology Changes the Game

The previous ASCO policy statement on genomic and genetic testing for cancer susceptibility was published in 2010 when direct-to-consumer genetic testing had just emerged and next-generation sequencing-based tests—which the new policy statement focuses on—were not yet available, Lindor said. “The clinical introduction of next-generation sequencing technology was much more rapid that generally was anticipated.”


Next-generation sequencing now permits broad, inexpensive testing for both germ-line and tumor DNA changes, which means clinicians can now test broad panels of genes or entire exomes for tumor DNA changes, Lindor said. But the new possibilities that arise from having these tests require a new standard for pre-test counseling to ensure that patients are ready for the results, she added—“and a recommitment to ongoing education for oncologists so they are prepared to provide the care indicated.”


Patients may not just find out what they intended to find out from a genetic test—such as a target for therapy or an explanation for a striking familial predisposition to a cancer, she continued. Patients being tested with newer technologies need to be prepared for the possibilities of finding variants in genes seemingly not related to their family history, gene variants for which there is not much literature (such as MRE11), variants of uncertain clinical significance (whether in well characterized disorders or in poorly characterized disorders), and variants known to cause severe autosomal recessive disorders, such as Ataxia Telangiectasia due to ATM mutations (in which case the heterozygote carriers will need to be educated about the potential risks associated with such mutations), she said.


The new statement reiterates the traditional counseling points from the previous ASCO recommendations, and also lists new points for multigene panel testing for germ-line variants, as well as for somatic testing, she said. “All of the principles of genetic counseling for a single gene test still apply, but the amount of information provided for each gene on a panel will of necessity need to be grouped or abbreviated in some manner.”


The updated policy statement reviewed evidence in and made recommendations for five key areas, which are summarized below (see “Recommendations” below).


A Call for Better Regulation

Another focus in the updated policy statement is support for regulation of laboratory-developed and commercial tests to maintain high-quality standards for such tests, but in a way that does not limit patient access or compromise innovation.


“A new paradigm is needed to attain a healthy balance of protecting the public from bad science yet not stifling innovation and not denying the public access to what information they could have, which one may argue may be better than nothing at all,” Lindor said.


“Most regulations were written with individual gene testing in mind with a focus on analytic validity and clinical validity. This approach will not scale to account for the fluid nature of ever-changing multigene panels and rapid growth of the knowledge base in genetics.” 


Ongoing Challenges

Among the ongoing challenges, Lindor said, will be to figure out how to provide high quality ongoing education for oncologists in practice about the new technologies so that their patients can benefit from the advances being made. “The time pressures and reimbursement challenges of today’s practices are not conducive to the careful discussions needed with patients; and there is a shortage of genetic providers in some health plans and in some geographic areas. So, the workforce needed to maximize use of genetics for patient care is not fully in place.”


And another big challenge will be the dearth of evidence and literature on various technology and outcomes as advances are made, she said.


Lindor noted that the closing paragraph of an editorial co-written by ASCO President Julie M. Vose, MD, MBA, FASCO; Past-President Peter Yu, MD, FACP, FASCO (first author); and President-Elect Daniel F. Hayes, MD, FASCO (JCO DOI: 10.1200/JCO.2015.63.3628), sums up the current dilemma: “Increasingly we will be the recipients of data that we did not anticipate, or perhaps, even seek to know. Accordingly we will be in the uncomfortable position of reacting to that data on the basis of an immature and incomplete understanding of what that data mean.”


In the editorial, Yu and co-authors highlight the importance of the updated policy statement and conclude by noting: “Robust discussions among a diverse set of stakeholders will be needed to ensure that all perspectives are listened to and that genetic cancer susceptibility services are comprehensive and patient-centric.”    


The updated policy statement reviews evidence in the following five areas and makes these recommendations:

1.     Germ-line Implications of Somatic Mutation Profiling:

  • ASCO calls for further research to develop best practices for the delivery of incidental and secondary germ-line findings;
  • ASCO encourages research aimed at improving understanding of patient preferences, optimal pre-test education and informed consent, and multi-level outcomes (such as patient, provider, health care system delivery, and cost) in this area;
  • ASCO recommends that laboratories choosing to conduct secondary analyses should develop mechanisms to report only somatic results for patients who decline to receive germ-line findings; and
  • ASCO recommends that patients be educated before testing about the possibility that germ-line variants might be identified and that providers communicate the limitations and risks of receiving germ-line findings.

2.     Multi-gene Panel Testing for Cancer Susceptibility:

  • ASCO asserts that providers with particular expertise in cancer risk assessment should be involved in ordering and interpreting multi-gene panels that include genes of uncertain clinical utility and genes not suggested by the patient’s personal and/or family history; and
  • ASCO encourages research to delineate the optimal use of panel-based testing, development of evidence-based practice guidelines as data emerges, and education of providers on the challenges of using these tests.

3.     Quality Assurance in Genetic Testing:

  • ASCO recommends appropriate regulation of tests that detect inherited genetic variants and supports a risk-based approach to FDA regulation for laboratory-developed tests and commercial tests—in a manner that does not compromise innovation or limit patient access to testing;
  • High quality standards should be adopted that allow providers and patients to understand the accuracy, benefits, and limitations of genetic tests conducted by individual laboratories; and
  • ASCO supports efforts to catalog and annotate all genomic variants and to create rigorously curated, open access libraries of the variants for use by all laboratories.

4.     Education for Oncology Professionals:

  • ASCO recommends continued education of oncologists and other health care professionals in cancer risk assessment and the management of individuals with inherited predisposition to cancer; and
  • ASCO recommends that oncology training programs develop a set of core skills for new trainees and ensure adequate time for achieving these skills.

5.     Access to Cancer Genetics Services:

  • ASCO calls for coverage policies that support access to cancer risk assessment and prevention services for individuals who are suspected to be at increased genetic risk;
  • ASCO opposes any payment policies that have the potential to negatively impact the care of patients with cancer by serving as a barrier to the appropriate use of genetic testing services; and
  • ASCO continues to support pre- and post-testing counseling when a patient is considered to be at risk for a hereditary susceptibility for cancer by a qualified health professional so that patients have the benefit of informed decision-making regarding genetic testing.

Monday, August 31, 2015

New research continues the promising preclinical results for the compound called crocetinic acid, a component of saffron. The study, by a team from the University of Kansas Medical Center NCI-Designated University of Kansas Cancer Center, showed that crocetinic acid inhibits hedgehog signaling, leading to a reduction in pancreatic cancer stem cells (Oncotarget 2015:5,13 Aug).


The agent was purified from commercial saffron using high-performance liquid chromatography. “Crocetinic acid inhibits proliferation of pancreatic cancer cell lines in a dose- and time-dependent manner,” wrote  the researchers, led by Animesh Dhar, PhD, Associate Professor in the Departments of Cancer Biology and Molecular and Integrative Physiology.


“Crocetinic acid induced apoptosis. Moreover, it significantly inhibited epidermal growth factor receptor and Akt phosphorylation. Furthermore, crocetinic acid decreased the number and size of the pancospheres in a dose-dependent manner and suppressed the expression of the marker protein DCLK-1 (Doublecortin

Calcium/Calmodulin-Dependent Kinase-1), suggesting that crocetinic acid targets cancer stem cells.”


The team (first author is Parthasarathy Rangarajan, PhD, a postdoctoral fellow in the Department of Molecular and Integrative Physiology) also noted that the data were confirmed in vivo, showing suppressed growth of tumor xenografts.


“Collectively, these data suggest that purified crocetinic acid inhibits pancreatic cancer stem cells, thereby inhibiting pancreatic tumorigenesis. The study indicates for the first time that purified crocetinic acid could be used as a novel therapeutic agent for pancreatic cancer.


“Further studies related to dosing and formulations would greatly benefit moving the compound to the clinic to determine therapeutic efficacy in humans affected by pancreatic and other cancers.”


Dhar noted via email that the researchers have now patented the compound and are looking to start a Phase I clinical trial.  


The research was supported by several National Institute of Health and National Cancer Institute grants.

--Serena Stockwell




Schematic representation of the mechanism by

which crocetinic acid inhibits tumor growth


Saturday, August 29, 2015



Recent news headlines have suggested that women with the earliest form of breast cancer should rethink undergoing treatment because it may not impact their long-term survival. But breast cancer experts interviewed for this article say the study results that spurred those headlines should not be interpreted as a message to forego or change standard treatment.


In the observational study, available online ahead of print in JAMA Oncology, scientists at the Women’s College Research Institute in Toronto, analyzed data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results database, which included information on 108,196 women with ductal carcinoma in situ (DCIS) who were followed for 20 years.


DCIS is the presence of abnormal cells inside a milk duct in the breast, the earliest form of breast cancer, often called "Stage 0." The lead study author, Steven A. Narod, MD, Senior Scientist and Director of the Familial Breast Cancer Research Unit, explained in an interview that DCIS is usually discovered during a mammogram, and that three standard treatment courses are typically available: lumpectomy, lumpectomy with radiation, or mastectomy. Sometimes medication is also prescribed. All the women in the study had received some type of treatment, he said.


Narod is also Professor in the Dalla Lana School of Public Health and the Department of Medicine at the University of Toronto, as well as a Tier 1 Canada Research Chair in Breast Cancer.


The study showed that women who undergo DCIS treatment have a 3.3 percent risk of dying of breast cancer after two decades--almost twice that by women in the general population.


"The three treatments seemed equivalent," Narod said. “Most of the women who died of breast cancer had cancer that had spread by the time they were diagnosed with DCIS. The DCIS had probably already metastasized when it was diagnosed and local treatment wasn't sufficient."


 Jennifer Litton, MD, Associate Professor in the Department of Breast Medical Oncology at the University of Texas MD Anderson Cancer Center, said it’s an interesting paper but that even more interesting has been the media coverage: "I think some people may have interpreted the paper based on their own bias or agenda. But when you read the paper, this was a very well-done, retrospective study using the SEER database of women with DCIS who received therapy and their outcomes. It does not tell us what happened to women with a diagnosis of DCIS who did not receive treatment."


According to the American Cancer Society, 60,290 new cases of carcinoma in situ (CIS) will be diagnosed in the United States in 2015. The big debate raised in the recent news articles was: "Which, if any treatment should women with DCIS undergo to avoid recurrence?"


Litton, who was not involved with the study, clarifies: "The new study doesn't tell us at all that women with DCIS shouldn't get treatment."


What it does offer, she said, is more a frame of reference. "This study does give us lovely background and insight into potentially who are the groups we should target for clinical trials in order to look at other methods of surveillance. But at this point, it in no way suggests that there should be a change to the standard of care in any practice."


Litton said there's always been a lot of interest in looking at women who need less intervention, but that clinical trials to determine this approach are needed.


"Clinical trials are difficult to do, but before we can change the standard of care we're going to have to do that. This research is interesting and hypothesis-generating but it isn't the information that tells us who we should and should not take to treatment.”

 Don Dizon, MD, Clinical Co-director of Gynecologic Oncology at Massachusetts General Hospital Cancer Center, said, "The big message should not be lost: the vast majority of women diagnosed with DCIS survive." Dizon was also not involved with the new study.


"DCIS is not a normal finding in the breast. So, finding something abnormal on histology prompts providers and patients for an action – what are we going to do about it? So much of decision-making is collaboration between those diagnosed and those who treat. I think it’s wrong to suggest that doctors and surgeons are recommending treatment “aggressive” or “not so aggressive” in the absence of discussion," Dizon told OT.


He said patients would bring their own goals and preferences to treatment: "What we need to do more of, or at least a better job of, is making sure that knowledge is imparted – inform the discussion through education of patients and their families, including making distinctions about in situ versus invasive breast cancer, and then informing our own treatments with the reasons why we do what we do."


Dizon said that if anything, these data suggest that breast cancer specialists can be much more thoughtful in their approach to DCIS.


"It is not a one-size-fits-all approach. For example, we might recommend breast-conserving surgery and radiation therapy to younger women with DCIS. But maybe for older women over 65, we need only surgery to remove the lesion and not radiation."


He said it’s also important to look at DCIS as separate from invasive breast cancer – that these new long-term data show that women do well, better than can be expected, compared with women with invasive breast cancer.


Dizon also noted that because SEER data was used, "We do not know what treatment patterns, or even what the second cancers were, for those who developed invasive disease. Such data could inform the results, and we need to be cognizant of that."


 Laura Esserman, MD, MBA, Professor in the Departments of Surgery and Radiology and Director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, wrote in an accompanying editorial that most of the women in the Narod et al study had lumpectomies and the rest had mastectomies. Some of the patients, she noted, were at higher risk, including younger patients under the age of 40, black women, and those with questionable molecular markers.


"The majority of DCIS is detected in women undergoing screening and who are recalled for biopsy of calcifications,” Esserman wrote. “To minimize the risk of overdiagnosis and/or overtreatment, it is time to reassess whether clustered amorphous calcifications should be a target for screening, recall, and biopsy, especially in older women.”


Esserman concluded by noting four points on what the sum total of the data on DCIS now suggests:

  • DCIS should be considered a “risk factor” for invasive breast cancer and an opportunity for targeted prevention;
  • Radiation therapy should not be routinely offered after lumpectomy for DCIS lesions that are not high risk;
  • Low- and intermediate-grade DCIS does not need to be a target for screening or early detection; and
  • Breast cancer specialists should continue to better understand the biological characteristics of the highest-risk DCIS cases and test targeted approaches to reduce death from breast cancer.

 Deanna Attai, MD, President of the American Society of Breast Surgeons and Assistant Clinical Professor in the Department of Surgery at UCLA David Geffen School of Medicine, who also spoke with OT, said the study generated so much interest among colleagues and the broader breast cancer community that she addressed it on her blog.


She told OT: "DCIS is not one disease. With each study that comes out, we get more and more evidence we're dealing with multiple diseases. Because we're dealing with multiple diseases, in a sense we need multiple treatment approaches--not a one size fits all.


“Look at the patient's age, tumor grade, extent of disease, along with a patient’s preferences and whether they understand these are our standard treatments but we're not sure about the long-term value of them in terms of improving survival. Couple that with understanding and recognizing that we don't have the ability to predict which patients will do well with less treatment."


Attai, a co-moderator of the weekly Breast Cancer Social Media tweetchat (#BCSM), also said physicians need to have open discussions with their patients regarding the differences between DCIS subtypes, and that patients and doctors themselves need to recognize their limitations.


"We need to acknowledge that we do not always have the right answers, inform the patient that decisions do not need to be made quickly, discuss cases in a multidisciplinary forum, and encourage second opinions. I think that is the ideal way to approach a patient with DCIS, and invasive cancer, as well."