Use Questions From Patients to Help Them Make Informed Treatment Decisions


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Recent reports about treatment options for patients with ductal carcinoma in situ, and the ensuing debate and comments played out in the media, may prompt increased questions from patients. A review summarizing data about these treatment options concluded that surgery and radiation therapy “remain the standard of care treatment options in the management of ductal carcinoma in situ” but recognized that recent observational studies have been interpreted as favoring a more conservative approach.

The lead author of the study, ­Chirag Shah, MD, a radiation oncologist at the Cleveland Clinic Taussig Cancer Institute, told The ASCO Post how physicians can use these questions to help patients make informed decisions and determine what is an acceptable increase in the risk of local recurrence.

Radiation Therapy: What Patients Should Know

There needs to be a discussion on the toxicities associated with endocrine therapy. Just as we discuss the toxicities associated with radiotherapy, there are toxicities associated with endocrine therapy, which can be short term as well as long term.
— Chirag Shah, MD

Patients considering radiation therapy need to know about the adverse effects of radiation to weigh them against the impact of higher rates of recurrence and salvage treatment. The upfront adverse effects of radiation are “typically a little bit of fatigue, redness of the skin, peeling of the skin,” Dr. Shah said. “Later side effects can be lightening or darkening of the skin, more firmness of the skin most commonly. With ductal carcinoma in situ, we don’t treat the lymph nodes, so there is a low risk of lymphedema, and shoulder stiffness is rare. The risk of lung irritation is quite low. If you use cardiac-sparing techniques for women with left-sided disease, you can reduce the dose to the heart and therefore reduce the risk of chronic cardiac toxicity.”

Endocrine Therapy: What Patients Should Know

“Endocrine therapy should be considered as part of adjuvant therapy for patients with ductal carcinoma in situ,” the review article noted, but because of concerns about noncompliance, the decision “should be guided by an informed discussion between the patient and the clinicians involved.” Those discussions should inform patients that endocrine therapy is generally needed for 5 to 10 years, “and the benefit may not be there if the patient is not compliant with therapy,” Dr. Shah said.

“Additionally, there needs to be a discussion on the toxicities associated with endocrine therapy. Just as we discuss the toxicities associated with radiotherapy, there are toxicities associated with endocrine therapy, which can be short term as well as long term,” Dr. Shah continued. “You can have decreased energy, hot flashes, joint aches, and muscle aches. Those are the most common ones we see.”

Patients should also be informed about “an increased risk of endometrial cancer with tamoxifen. We also counsel patients about that. We tell them the risk is extremely low, but we do let them know, so they are aware of that,” concluded Dr. Shah. ■

Disclosure: Dr. Shah reported no potential conflicts of interest


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Surgery and Radiation Therapy Remain Standard of Care for Managing Ductal Carcinoma in Situ

A review of more than 50 studies (many randomized controlled trials) concluded that surgery and radiation therapy “remain standard-of-care treatment options” in the management of ductal carcinoma in situ.1 The review continues the widely reported discussion on managing ductal carcinoma in situ,...


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