The diagnosis of cancer is an incredibly frightening experience for anyone. That’s why it’s crucial for us to reconsider how we define cancer. Despite the significant progress we’ve made in understanding the disease, we have failed to update our definition of what is considered the most serious illness.
Some cancers have minimal impact on the quality and length of life but are still classified alongside those that do. This often results in unnecessary treatment, physical changes, side effects, and a range of psychological, relationship, and financial challenges. As oncologists specializing in prostate and breast cancers, we believe it is essential for the medical community to reevaluate how we categorize cancer in its early stages. Many cancer experts around the world share this viewpoint.
The term “cancer” dates back to Hippocrates, who used it around 2,500 years ago, although evidence of the disease existed in Egyptian times, 2,500 years prior. In the past, tumors could be detected by sight or touch. Today, we rely on blood samples, biopsies, and microscopic analysis of surgically removed specimens to identify cancer. However, with more advanced technologies, we now find medical conditions that may have gone unnoticed without causing harm. This overdiagnosis phenomenon is well-documented in breast and prostate cancer screenings.
The idea of early cancer detection is appealing and often life-saving. However, labeling something as cancer can lead to aggressive treatment, even if the cancer is unlikely to cause problems. In many cases, the use of the term “cancer” does not accurately reflect the behavior of the disease. As cancer surgeons, knowing what we do now, we often wish we could change the diagnosis or reclassify many of our patients.
Let’s consider two examples: Gleason 6 grade prostate cancer and ductal carcinoma in situ (D.C.I.S.). Both are considered low or very low risk. Roughly 20-25% of prostate and breast cancer diagnoses in the United States fall into this category, affecting around 100,000 people annually. Despite being non-life-threatening and asymptomatic at the time of diagnosis, these patients often receive surgery or radiation treatment. It is unlikely that Gleason 6 or D.C.I.S. will spread to other parts of the body unless more aggressive cancer forms or coexists. They are better understood as risk factors for prostate or breast cancers with malignant potential.
Many patients feel compelled by concerned loved ones to pursue treatment upon receiving a cancer diagnosis. A dictionary definition of cancer describes it as a malignant tumor with unlimited growth potential that invades locally and spreads systemically. Patients assume that without treatment, the condition will quickly lead to metastasis and death. Consequently, they choose aggressive treatments they may not need.
We need alternative approaches. Personalized screenings based on individual risk factors can help identify who is at risk for specific types of cancer and determine when and how often to screen. This approach is being explored in breast cancer through a study conducted by Dr. Esserman, which aims to replace annual mammograms with more tailored screening schedules. Another approach is active surveillance, where very early-stage cancer is closely monitored and treatment is delayed until necessary. Sweden leads the way in adopting this approach for early-stage prostate cancer, with 90% of patients enrolled. In the United States, only 60% of patients follow this protocol. Long-term studies have shown that the risk of metastasis or death from prostate cancer in these cases is incredibly low.
For D.C.I.S., there is a strong rationale for active surveillance and risk-reduction strategies, but these approaches have not been widely offered or tested in clinical trials until recently. Renaming very low-risk cancers would help patients understand and embrace monitoring and risk-reduction approaches. These early-stage “cancers” meeting microscopic criteria but not clinical criteria can be designated as IDLE (indolent lesion of epithelial origin) or preneoplasia, avoiding the dreaded C-word.
Other cancers, such as thyroid, bladder, kidney, and cervical cancers, have already undergone name changes, resulting in fewer unnecessary surgeries. These conditions do not require emergency intervention, and there is ample time to learn about the disease, evaluate treatment options, or participate in clinical trials.
Clinical surveillance studies have proven successful in reducing overtreatment for Gleason 6 prostate cancer. Similarly, active surveillance with targeted therapies has the potential to manage D.C.I.S. effectively. Clinical trials are essential in driving change within the field, as they have done with prostate cancer. However, the fear associated with the word “cancer” often leads patients to avoid participating in studies or protocols that could minimize overtreatment.
Changing the label would alleviate stress for patients and their families, significantly reduce unnecessary treatments, and improve screening for life-threatening cancers. While some argue that early-stage cancer patients may have unseen regions of their prostate or breast with riskier cancers, it should not be routine to treat based on hypothetical scenarios. We have various tools for accurate diagnosis, and we should utilize them.
By modifying the names of early-stage prostate and breast “cancers” to better reflect their behavior, we can reduce unnecessary treatment and its side effects while improving screening, prevention, and care.
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