Three Medical Journals Concurrently Publish the Findings of Specialists From Jefferson and Around The World
A who's who of breast cancer experts from Jefferson Medical College of Thomas Jefferson University, and medical institutions around the world have designed a system for classifying Ductal Carcinoma In Situ (DCIS), a controversial malignancy found in the breast, as a first step toward improving patient treatment for this type of early breast cancer. DCIS currently represents 20 to 25 percent of all breast cancers diagnosed.
In a paper published concurrently by three medical journals, Cancer, Human Pathology and The Breast Journal, the international Consensus Conference Committee outlines a classification system for DCIS that takes into account how the cancer cells appear under the microscope (nuclear grade), the amount of tissue death (necrosis), the cells' arrangement (polarization) and their physical shape (architecture).
Physicians from Around the World Attend Consensus Conference at Jefferson
The Consensus Conference hosted at Jefferson was chaired by Gordon Schwartz, MD, MBA, Professor of Surgery, Jefferson Medical College. "Now when DCIS is encountered in Timbuktu, it will be classified the same way as in Philadelphia or Washington, DC, or London," said Dr. Schwartz.
The committee designed the classification system during a weekend-long conference held April 25-28 at Jefferson. The conference was supported by the Breast Health Institute and the Fashion Institute International both of Philadelphia, as well as Thomas Jefferson University Hospital and Jefferson Medical College.
The committee members include pathologists, mammographers, surgeons, a radiation oncologist and a biostatistician, from Jefferson and medical institutions around the globe. Participants from Jefferson include Gordon Schwartz, MD, Professor of Surgery, JMC; Roland Schwarting, MD, Associate Professor of Pathology, Anatomy and Cell Biology, JMC; Fred Gorstein, MD, The Jacob and Sophie Rubin Professor and Vice Chairman of the Department of Pathology, Anatomy and Cell Biology, JMC; Gerald Finkel, MD, Clinical Professor of Pathology, Anatomy and Cell Biology, JMC; Juan Palazzo, MD, Assistant Professor of Pathology, Anatomy and Cell Biology, JMC; and Stephen A. Feig, MD, Professor of Radiology, JMC, and Director of the Jefferson Breast Imaging Center.
The report's significance in determining the recommended approach for DCIS is confirmed by the fact that three journals have agreed to publish the paper at the same time. "It's rarely been done," said Dr. Schwartz of the multiple journal publishings. "By chance, not by design, three of the physicians who attended the conference are also the editors-in-chief of the three journals. They thought it was important enough to reach all three journal audiences."
Consensus Committee Determines Uniform Classification of DCIS
"DCIS can be described as looking like a cluster of salt granules on a mammogram. Although a majority of patients with DCIS will not develop a more threatening cancer, in some patients, the DCIS can progress to become an invasive, life-threatening malignancy," Dr. Schwartz said. "Until now, the greatest challenge for physicians who treat DCIS has been to discriminate between the less aggressive and more aggressive forms of the disease."
As a result, the treatment of DCIS has ranged from mastectomy to a combination of lumpectomy and radiation treatment to lumpectomy alone, depending on the physician's judgment. Until the late 1970s, mastectomy was always the standard treatment for DCIS.
"If you can't define it, you can't treat it properly," Dr Schwartz said. "The subtleties of classification are such that the treatments may be different based upon how the slight differences of DCIS are perceived. So we tried to get these experts to agree upon a uniform system of classification."
The consensus of these international specialists was to identify a set of factors in descending order of importance: how the cancer cells appear on the miscroscope (Nuclear Grade); amount of tissue death (Necrosis); cell formation (Polarization); and morphology (Architecture). The conferees also concluded that the size and distribution of the DCIS should also be taken into account in classifying the cancer.
As part of their report, the breast cancer specialists recommended a process for removing and evaluating breast tissue for DCIS, and that the radiologist, surgeon and pathologist work as a unified team in this effort. The conferees suggested that the traditional surgical procedure involving a needle-guided localization be employed in removal of the tissue sample. It is also recommended that metallic clips be placed on the tissue specimen near the site of the DCIS if the calcifications shown on the mammogram are faint or within a very small area of the specimen.
In addition the conferees recommended that biologic markers such as estrogen and progesterone receptors or nuclear proliferation antigen Ki-67, for example, be determined in each case, although these markers are not currently used to determine treatment. Dr. Schwartz noted that Jefferson is in the forefront in the use of these biologic markers.
Now that the conference has determined a means for better identifying DCIS, the next step is to determine a universally acceptable clinical use for the classification system, the conference report states. The conferees said they hope to meet again in the near future to map out that strategy.
The conference was funded through the annual "Give the Shirt Off Your Back! Fight Breast Cancer" gala dinner dance and silent auction sponsored by the Breast Health Institute and the Fashion Group International-Philadelphia.