When is active surveillance of a tumor appropriate?

Dear Dr. Roach: In a recent column, you addressed breast cancer in an older woman. She expressed concern about overtreatment of small tumors and if just keeping an eye on the tumor (active surveillance) might be a way to go.

Do you think active surveillance might be an option at any age in a woman’s life, rather than chemo and radiation for some tumors? Is that form of treatment appropriate, and could it be a better option for a better quality of life for the patient? — G.C.

Answer: “Active surveillance” refers to not treating a lowerrisk condition initially, but actively monitoring it to look for signs that it might be changing to a condition with greater risk. This is a preferred means for many men with very-low-risk or low-risk prostate cancer. A recent trial has been started and is recruiting women with DCIS (ductal carcinoma in situ) to see whether active surveillance might be reasonable for this condition as well. I think this is an important study, with the potential to affect many women who otherwise are recommended for lumpectomy, sometimes with radiation. Many women, in fact, opt for a total mastectomy for this condition, and if we can identify women who might not need such invasive procedures, that would be a major benefit.

However, for a woman with invasive intraductal breast cancer (which is a much more aggressive tumor than DCIS, usually), I can’t recommend active surveillance. Older women with this diagnosis, or those with one of many other medical conditions, still can receive medication, like an antiestrogen, which has far fewer side effects than surgery or traditional chemotherapy.

Women who would not consider treatment of an invasive breast cancer should reconsider getting a mammogram in the first place.