Nancy Ulene, 43, wasn't particularly worried when a routine mammogram turned up something her radiologist thought was fishy. She had had a tumor seven years earlier that turned out to be benign. But this time was different. A biopsy confirmed that Ulene, the niece of former Today show medical expert Art Ulene, had ductal carcinoma in situ, or DCIS, a growth that is variously described as either an early-stage breast cancer or a precancerous lesion. "It was very confusing," says Ulene, a color stylist for Walt Disney TV Animation. "I needed to know more."
What she soon learned was that the kind of cancer she had--a group of malignancies so tiny that they were rarely seen before the advent of mammograms powerful enough to spot them--is at the heart of a raging debate in the cancer community. Doctors know what to do when they find tumors the size of marbles or plums. That's what surgery, radiation and chemotherapy are for. But what do you do with cancers the size of pencil points? Do you treat them as you would a massive tumor? Do you leave them alone? Should you even be looking for them in the first place?
This year, according to the American Cancer Society, some 200,000 women (and 1,500 men) will learn that they have breast cancer--up from a little more than 100,000 two decades ago. While the death rate from the disease has dropped modestly over the past decade, there is a growing sense of frustration among cancer experts. Part of the problem is DCIS. Thirty years ago, these miniature tumors, which usually don't spread into the rest of the body, were diagnosed in some 6% of breast-cancer patients. Today the ratio is closer to 20%, largely because of advances in detection techniques. Yet the treatment of choice is still surgery followed by radiation. "We may be far overtreating our patients," says Dr. Julie Gralow, an oncologist at the Fred Hutchinson Cancer Research Center in Seattle. "We've now got women being diagnosed with tumors that probably never would have been treated if we didn't have mammography. They probably would have lived long, natural, healthy lives never knowing they had breast cancer."
The long-simmering debate over the value of routine mammograms flared up again last month because of new questions about whether the test has been sufficiently proved to save lives (see box). But the mammography squabble masks a deeper problem: advances in screening and diagnostic technology have outpaced treatments, leaving cancer patients and their doctors struggling to make treatment choices neither are prepared to make.
That's the bad news. The good news is that the situation is on the mend. Basic research into the molecular chemistry of cancer is well funded and advancing steadily, delivering better diagnoses and smarter drugs. Meanwhile, a series of dramatic improvements in the tools of treatment are moving into clinical trials, promising patients kinder, gentler ways to treat their cancers. Among the highlights:
--Surgeons are developing several techniques that destroy tumors while sparing more breast tissue--without reducing the chances of survival. (This can be particularly important for small-breasted women who don't necessarily have a lot of tissue to spare in the first place.)