PhotoWhile scientists in the laboratory continue to search for a cure for cancer, doctors who treat it have made huge strides in raising cancer awareness. Screening programs now routinely catch the disease in its early stages.

But have we gone overboard in treating cancer? A panel of scientists convened by the National Cancer Institute (NCI) and chaired by a UC San Francisco (UCSF) breast cancer expert believes we have. The group is proposing a major update to the way the U.S. approaches diseases now classified as “cancer.”

Writing this week in the Journal of the American Medical Association, the panel points out that, despite the advancements in cancer screening, we still haven't achieved the decline in serious disease and death that you might expect.

The problem, it seems, is that these screening programs are not just identifying malignant tumors. They also detect what turn out to be slow-growing, low-risk lesions, and sweeping them into the same treatment process.

Harmless cancer?

As a result, patients are being diagnosed and treated for forms of cancer that might never do any harm. The phenomenon has been termed “overdiagnosis,” which translates to “too much medicine.”

“By recognizing that cancer is not one disease, but a number of different diseases, we can individualize our treatment based on biology and avoid overtreatment,” said panel chair Dr. Laura J. Esserman, director of the Carol Franc Buck Breast Care Center at UCSF. “The goal going forward is to personalize screening strategies, and focus screening policies on the conditions that are most likely to result in aggressive illness and death.”

This may strike some patients – and perhaps even some physicians – as a somewhat controversial position. In the mind of the public cancer is a dreaded disease that is not to be taken lightly. The very word “cancer” uttered in a doctor's office is enough to terrify most patients.

New classification

PhotoFor that reason, the panel is recommending that the word be used less often. For example, the authors think there should be a new classification for tumors that are called “indolent,” meaning they aren't likely to cause harm. Under their guidelines ductal carcinoma of the breast -- currently considered the earliest form of breast cancer -- would no longer be called cancer.

This is not to suggest they think screening should be de-emphasized – just the opposite. Rather, screening strategies should be improved to avoid over-treating tumors that would not be lethal, or that would not even have come to medical attention.

“Although our understanding of the biology of cancer has changed dramatically, perceptions on the part of the public, and among many physicians, have not yet changed,” Esserman said. “Cancer is still widely perceived as a diagnosis with lethal consequences if left untreated.”

Other scientists have suggested in the past that some forms of prostate cancer don't always require treatment. Earlier this year UCSF researchers suggested men might need less treatment for prostate cancer unless they happen to harbor the gene for the most aggressive form of the disease.

They're using a new genomic test for prostate cancer that can help predict a man's genetic risk of the most severe form of the disease. They say some men who have been diagnosed with prostate cancer may be able to avoid surgery, and most treatment altogether, if they have what is considered a manageable form of the disease.

There are other forms of cancer that may also fit into this category. The authors of the NCI report say overdiagnosis is occurring across many medical conditions, but is especially common in breast cancer, lung cancer, prostate, thyroid cancer and melanoma.

Exceptions

On the other hand, they cite colon and cervical cancer as examples of “effective screening programs in which early detection and removal of precancerous lesions have reduced incidence as well as late-stage disease.”

Obviously, any suspicion that a condition is cancerous must be taken seriously and be brought to your doctor's attention immediately. However, if the NCI panel is to be believed, not every cancer will require the lengthy, expensive and often grueling treatment cancer normally receives.

“Although no physician has the intention to overtreat or overdiagnose cancer, screening and patient awareness have increased the chance of identifying a spectrum of cancers, some of which are not life threatening,” the authors wrote. “The ultimate goal is to preferentially detect consequential cancer while avoiding detection of inconsequential disease.”


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