Should ESPN Anchor Hannah Storm’s Early Breast Cancer Have Really Been Treated Or Simply Watched Carefully?

Her breast cancer story is also a great reminder for women to get their annual breast cancer screenings and understand the debates that exist with regard to DCIS.

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Speaking to “Good Morning America” this week, Storm said, “I was shocked because, again, I had had mammograms every year. I have no risk factors. I have no breast cancer in my family. I did not have a lump. I did not have pain. I don’t have any genetic predisposition to breast cancer.

RELATED: 58% Drop In Breast Cancer Death Rate: Why Katie Couric, 67, And So Many Women Are Now Beating Breast Cancer

“And what I came to learn is the vast majority of women who are diagnosed with breast cancer don’t have risk factors, and so I’ve got to say I was shocked. I was scared. I was very, very lucky because they found it so early.”

She continued, noting she hopes to encourage others to get screening for breast cancer, “I know so many people who don’t have mammograms, who are scared to have them.

“I don’t want them to be scared. I want them to be scared not to have this information.”

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Screening for breast cancer is generally recommended, and thought of as a good thing. However, the issue with screening is that not all doctors agree that every cancer that’s detected needs to be treated, or that the benefits of treatment outweigh the side effects. From the patient’ perspective, when most people are told they have cancer, they want it out!

RELATED: Explore SurvivorNet’s digital guide to next-generation sequencing for breast cancer. 

Dr. Alana Welm, of the Huntsman Cancer Institute, previously told SurvivorNet that doctors need to find a balance between screening and finding cancers that actually require treatment.

Screenings lead to more people being diagnosed with cancer, and some of those cancers may have never caused an issue. Dr. Welm says treating these cancers exposes patients to unnecessary toxicities. Stage zero breast cancer, for example, can get picked up during screening but not all doctors see eye-to-eye on whether it requires treatment or just monitoring.

Finding a Balance Between Screening and Treating

Stage Zero Breast Cancer

Stage zero breast cancer refers to Ductal Carcinoma In Situ (DCIS). DCIS are abnormal cells that line the duct in a breast. A normal breast is made up of lots of ducts (these ducts carry milk to the nipple in a woman who is lactating).

Learning About Stage Zero Breast Cancer (DCIS)

DCIS is not an invasive cancer, meaning it hasn’t spread outside the milk duct and it cannot invade other parts of the breast. In some instances, if left untreated, doctors believe that DCIS can evolve into a more invasive breast cancer. This is why historically, the standard treatment for DCIS is to remove it surgically and in some instances offer radiation as well.

However, many doctors aren’t sure if even that is necessary for DCIS, because it may or may not turn into cancer.

And in an effort to reduce the fear around the earliest stage breast cancer we want you to understand the definition and the debate around treatment.

Two important facts about DCIS breast cancer are:

• It doesn’t spread to other parts of the body.
• The risk of death is essentially zero.

Why Active Surveillance is Being Studied for Stage Zero Breast Cancer

As for the debate, some doctors don’t consider it cancer, but rather a collection of abnormal cells or a pre-cancer, which is why some women opt for a watch-and-wait approach.

Others may recommend the surgery route which usually involves a lumpectomy and potentially radiation as well. This somewhat more aggressive treatment (which is the standard protocol at major cancer centers) does have side effects, and potentially, long-term effects.

Dr. Elizabeth Comen Explains The Main Aspects Of Early-stage Breast Cancer

Less commonly, doctors and their patients will decide on more aggressive approaches depending on the amount of DCIS in the breast and a woman’s specific risk factors for future breast cancer. One reason some doctors may want to remove DCIS is if a biopsy reveals any evidence that a more invasive breast cancer could be present.

Meanwhile, a large study, known as the COMET study, is now in the works, looking at the benefit of active surveillance versus standard treatment.

This kind of study will help doctors determine whether doing less may be just as effective as doing more. In the meantime, the options are worth weighing depending on your individual diagnosis and concerns.

Treatment Controversy

Dr. Laura Esserman, a surgeon and breast cancer oncology specialist practicing at the UCSF Breast Care Center, previously launched WISDOM, “Women Informed to Screen Depending on Measures of Risk,” about eight years ago after seeing women get diagnosed with all stages of breast cancer getting similar treatments, whether that be surgery, chemotherapy, or radiation.

The WISDOM trial’s official website explains the study “is testing a personalized approach to screening compared to annual mammograms.”

According to the National Institute of Health,  WISDOM “is a randomized trial to assess whether personalized breast cancer screening—where women are screened biannually, annually, biennially, or not at all depending on risk and age—can prevent as many advanced (stage IIB or higher) cancers as annual screening in women ages 40–74 years across 5 years of trial time. The short study time in combination with design choices of not requiring study entry and exit mammograms for all participants may introduce different sources of bias in favor of either the personalized or the annual arm.”

Speaking to the NobHill Gazette earlier this year, Esserman, explained, “By starting with risk assessment, it gives you the opportunity to think about prevention and screening. And you need both.

“Screening alone isn’t prevention; it’s just finding things early. Which is not always good, because sometimes you find DCIS [ductal carcinoma in situ] or early things that people treat probably more aggressively than they need to. … Because if you find DCIS, which you often find in the 40s, a lot of those women wind up with bilateral mastectomy or unilateral mastectomy because they’re so frightened because they hear the word ‘cancer.'”

She continued, “But it’s not cancer. And there are other options. Some people have a focal mass, some people don’t. I don’t think all of those DCIS lesions are really surgical lesions. I’m a surgeon. That doesn’t mean that I want to use my craft where it doesn’t work.”

We're really excited about this new phase of WISDOM and hope everyone who is eligible (women aged 30-74 not previously diagnosed with breast cancer) will join us and help make the future better for themselves and every women they know!https://t.co/KEOXKTLEsP

— Dr. Laura Esserman (@DrLauraEsserman) February 6, 2024

Meanwhile, Dr. Heather Greenwood, an associate professor of clinical radiology in the Breast Imaging section at UCSF Radiology & Biomedical Imaging, also feels the same way.

Dr. Greenwood said, “As a breast radiologist I believe the data has proven that annual screening mammography starting at 40 is what has been proven to reduce mortality from breast cancer.

“However, we also know that mammography is far from a perfect exam, as we are failing so many young women who have dense breasts (decreasing the sensitivity of mammography) or women younger than 40 who have not been identified as high risk and therefore are not getting screened.”

As for the WISDOM trial, high-risk women will be identified. Dr. Greenwood explained, “This past year I met a patient whose breast cancer was caught very early on a screening MRI. She only got the MRI because she was identified as high risk through her participation in the WISDOM study.”

Additionally, Dr. Apar Gupta, assistant professor of radiation oncology at Columbia University Vagelos College of Physicians and Surgeons and lead author of an earlier study regarding DCIS treatment, understands that not all treatments for invasive breast cancer is ideal for DCIS.

The study is titled, “Cost-Effectiveness of Adjuvant Treatment for Ductal Carcinoma In Situ,” and was published in the Journal of Clinical Oncology in May 2021.

Speaking to the Columbia University Irving Medical Center back in 2021 about how his study’s findings can assist providers and their patients find the best treatment to DCIS, Dr. Gupta said, “We know that some cases of DCIS will transform into invasive cancer if not treated, but there is a large degree of uncertainty as to just how many—with estimates ranging from 20% to 50% of cases. We will get a more precise estimate through recently established trials in which DCIS patients are closely monitored instead of undergoing surgery.

“Thus far, we have been focused on reducing that risk at all costs and treating DCIS like an early-stage breast cancer: The first step is surgery—usually lumpectomy—followed by radiation treatment for three to four weeks and finally hormone therapy for five years. These treatment recommendations are based on clinical trials from 15 to 20 years ago that showed radiation therapy and hormone therapy cut the risk of recurrence by about a half and a quarter, respectively. Adding hormone therapy to radiation has an even smaller absolute benefit.”

He explained further, “It’s important to understand that radiation and hormone treatments do not change survival—the 10-year survival rate for women diagnosed with DCIS is 98% regardless of whether they receive either treatment. These treatments instead reduce the risk of breast cancer down the road.

“Since treatment of DCIS after surgery doesn’t improve survival, there is a growing concern that DCIS may be overtreated if the benefit of these treatments is outweighed by their impact on quality of life.”

Dr. Gupta also pointed out how “shared decision making is important for any cancer treatment,” adding, “Physicians and patients alike should consider personal preferences and tolerance for side effects versus the risk of recurrence. For patients with low-risk DCIS, though our study found that the benefits of radiation therapy are lower relative to its costs, if a patient is anxious about the risk of recurrence, it may make sense to pursue radiation—her quality of life will be better because we reduced her anxiety.”

“The same may be true for hormone therapy. Some patients want the most aggressive treatment course and are more willing to tolerate side effects, and a case could be made for hormone therapy for these patients. Other patients don’t want treatment at any cost. Most patients fall somewhere in between,” he concluded.”

Deciding the Right Course of Breast Cancer Treatment

Doctors treating breast cancer seek out markers on your particular cancer to help decide what course of treatment is best for you. This is due to the cancer cells possibly having what are known as receptors that help identify the unique features of the cancer.

The three main receptors are the estrogen receptor, the progesterone receptor, and the HER2 receptor. The estrogen and progesterone receptors go together because they are fueled by hormones. Think of the cancer cell as having little hands on the outside of the cell which grabs hold of proteins that help it grow. These proteins are sometimes called “ligands.”

An example of a type of ligand that can stimulate a cancer cell is the hormone estrogen. An estrogen receptor-positive breast cancer will be stimulated by estrogen to grow.  In this instance, your doctor may offer you treatment to specifically target the estrogen receptor.

The Unique Features of Breast Cancer

Another important receptor to test for is the HER2 receptor. For HER2 positive breast cancers (like the stage zero cancer Kerns was diagnosed with), therapies that uniquely target the HER2 receptor are essential to treating the disease.

Helpful Information About Breast Cancer Screening

The medical community has a consensus that women between 45 and 54 have annual mammograms. However, an independent panel of experts called the U.S. Preventive Services Task Force (USPSTF) is saying that women should start getting mammograms every other year at the age of 40, suggesting that this lowered the age for breast cancer screening could save 19% more lives. For women aged 55 and older, the American Cancer Society recommends getting a mammogram every other year. However, women in this age group who want added reassurance can still get annual mammograms.

Women with a strong family history of breast cancer, have dense breasts, have a genetic mutation known to increase the risk of breast cancer, such as a BRCA gene mutation, or a medical history, including chest radiation therapy before age 30, are considered at higher risk for breast cancer.

WATCH: Understanding the BRCA gene mutation

Experiencing menstruation at an early age (before 12) or having dense breasts can also put you into a high-risk category. If you are at a higher risk for developing breast cancer, you should begin screening earlier.

Breast density is determined through mammograms. However, women with dense breasts are at a higher risk for developing breast cancer because dense breast tissue can mask potential cancer during screening. 3D mammograms, breast ultrasound, breast MRI, and molecular breast imaging are options for women with dense breasts for a more precise screening. It is important to ask your doctor about your breast density and cancer risk.

Family History & Breast Cancer Risk

Although breast cancer can happen to anyone, certain factors can increase a person’s risk of getting the disease. The known risk factors for breast cancer include:

• Older age
• Having a gene mutation such as the BRCA1 or BRCA2
• Added exposure to estrogen
• Having children after the age of 30
• Exposure to radiation early in life
• Family history of the disease

RELATED: Is Genetic Testing Right for You?

Different types of genetic testing can help people with a family history of cancer better ascertain their cancer risks. Your doctor will discuss your family history of cancer with you in the context of your type of tumor and your age at diagnosis. Hereditary genetic testing is usually done with a blood or saliva test.

WATCH: Understanding genetic testing for breast cancer.

About ten percent of breast cancers are hereditary, says Dr. Ophira Ginsburg, Director of the High-Risk Cancer Program at NYU Langone’s Perlmutter Cancer Center.

“We encourage only those with a family history to get [genetic testing],” Dr. Ginsburg tells SurvivorNet. “I would say that if you have anyone in your family diagnosed with a rare cancer. Or if you have a strong family history of one or two kinds of cancer, particularly breast and ovarian, but also colon, rectal, uterine, and ovarian cancer, that goes together in another cancer syndrome called the Lynch Syndrome,” Dr. Ginsburg adds.

The second test involves the genetic sequencing of your tumor if you’ve been diagnosed with cancer by this point. These genetic changes can be inherited, but most arise during a person’s lifetime. This process usually involves examining a biopsy or surgical specimen of your tumor. This testing can lead to decisions on drugs that might work against your cancer.

“Digital mammography, it turns out, significantly improves the quality of the mammogram… It’s 3D or tomosynthesis mammography,” Dr. Lehman explains.

“This allows us to find more cancers and significantly reduce our false-positive rate. With digital mammography 3D tomosynthesis, we’re taking thin slices through that breast tissue, like slices of a loaf of bread. We can look at each slice independently rather than trying to see through the entire thickness of the entire loaf of bread. So those thin slices help us find things that were hidden in all the multiple layers,” Dr. Lehman adds.

Additional testing can be considered for dense breasts, depending on a woman’s personal history, preferences, and her physician’s guidance.

WATCH: How Trodelvy Offers Hope

What to Consider When Weighing Preventive Mastectomy?

A prophylactic, or preventative, mastectomy is an operation where the breast tissue is removed to prevent cancer from developing in the future.

“Risk-reducing mastectomies are an operation where we take women at, usually, very high risk for getting breast cancer for genetic mutation carriers, who are the ones at the highest risk; there’s unfortunately only one way to actually prevent breast cancer,” Dr. Elisa Port, Chief of Breast Surgery at Mount Sinai Health System, previously told SurvivorNet.

“Women who are found to test positive for a genetic mutation really have two options,” Dr. Port explains. “One is what’s called high-risk surveillance, which means we check them every six months or so mammograms, MRIs with the hope that if God forbid, they develop breast cancer, we pick it up early. But that’s not prevention; that’s early detection.

“Early detection is a goal; it’s not a guarantee. For the woman who wants to be more proactive about actually preventing breast cancer, or as we say reducing her risk, unfortunately, the only way to do that is to remove the actual tissue at risk, and that is the breast tissue,” she adds.

Some women decide to have their breasts reconstructed and have implants put in right after the mastectomy, while others don’t have reconstruction at all.

The benefits of a prophylactic or preventative surgery are:

• Significant reduction in cancer risk (from 80-90% to 1-2%)
• Nipples can often be spared
• Women can get reconstruction at the same time

Contributing: SurvivorNet Staff

Learn more about SurvivorNet's rigorous medical review process.

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