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Rethink cancer detection and treatment, expert panel advises

© Enrique Castro-Mendivil / Reuters
Early screening programs for breast and prostate cancers have led to clinically insignificant decreases in deaths from the disease.

We need to rethink our approach to cancer detection and treatment, including how we use the term cancer, according to recommendations published Monday in the Journal of the American Medical Association (JAMA) by a panel of distinguished cancer physicians and scientists.

As the experts, who were convened last year by the National Cancer Institute, point out, the purpose of early detection is to reduce the incidence of late-stage cancer and cancer deaths. But those goals have not always been met.

“National data demonstrate significant increases in early-stage disease, without a proportional decline in later-stage disease,” the experts explain.

“What has emerged,” they add, “has been an appreciation of the complexity of the pathologic condition called cancer. The word ‘cancer’ often invokes the specter of an inexorably lethal process; however, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death.”

Indolent lesions

Early screening programs have successfully reduced the incidence of a few late-stage cancers, most notably cancers of the colon and cervix, acknowledge the experts. But other early screening programs, such as those for breast and prostate cancers, have led to clinically insignificant decreases in deaths from the disease.

Too often, the experts note, early screening technology identifies indolent lesions (also sometimes called incidentalomas), which are unlikely to progress and harm patients during their lifetime. Yet, once those lesions are detected, the patients and their physicians feel obliged to biopsy and treat them. Thus, many patients are receiving unnecessary treatments, including invasive surgery and toxic radiation and drug therapies.

“An ideal screening intervention focuses on detection of the disease that will ultimately cause harm, that is more likely to be cured if detected early, and for which curative treatments are more effective in early-stage disease,” the experts write.

Even after more than 30 years of technological advances, those screening interventions remain elusive for the vast majority of cancers.

Needed: new terminology

In their call for change, the experts makes several specific recommendations to the National Cancer Institute, including the following:

  • “Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with cancer screening.” Overdiagnosis is particularly a concern, the experts point out, with early screening technologies meant to detect cancers of the breast, lung, prostate and thyroid.
  • Change cancer terminology based on companion diagnostics.” The term cancer should be reserved only for lesions that have a reasonable chance of becoming deadly if untreated, suggest the experts. That means premalignant conditions, such as the one in the breast known as ductal carcinoma in situ (DCIS), should be reclassified as an IDLE (indolent lesions of epithelial origin) condition, and the word carcinoma should be removed from its name. Doing so would give patients a more accurate — and less frightening — description of the lesion and make them less likely to seek unnecessary treatment.
  • “Mitigate overdiagnosis.” The experts point out that several strategies are needed to minimize the overdiagnosis and overtreatment of indolent disease, including reducing the frequency of cancer-screening exams and focusing screening on high-risk populations.

“Although no physician has the intention to overtreat or overdiagnose cancer,” the panel of experts conclude, “screening and patient awareness have increased the chance of identifying a spectrum of cancers, some of which are not life threatening. Policies that prevent or reduce the chance of overdiagnosis and void overtreatment are needed, while maintaining those gains by which early detection is a major contributor to decreasing mortality and locally advanced disease.”

You can read the full recommendations on the JAMA website.

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