What Do You Mean, It’s Not Cancer?

Cancer” is the word of the week. A catchall term that really describes a bouquet of serious as well as not-so-troubling illnesses, the word has raised quite a ruckus. The discussion started among doctors, not with patients and their families. It escalated immediately after the online publication of a cancer perception study in JAMA (the Journal of the American Medical Association).

“Everyone is seeing some kind of agenda here, seeing what they want to see based on whatever grievance they have,” one perceptive commenter pointed out yesterday afternoon.

“The impetus behind the call for change,” Tara Parker-Pope explained in Tuesday’s New York Times, “is a growing concern among doctors, scientists and patient advocates that hundreds of thousands of men and women are undergoing needless and sometimes disfiguring and harmful treatments for premalignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.”

Especially concerning are the seemingly “easier” types of early cancers, such as Barrett’s esophagus, ductal carcinoma of the breast in situ, and nonaggressive prostate cancer. Many health practitioners believe illnesses like these might be better reclassified as IDLE (indolent lesions of epithelial origin) conditions.

Here’s what the researchers have to say. “Over the past 30 years, awareness and screening have led to an emphasis on early diagnosis of cancer,” began study authors Laura J. Esserman, MD, MBA, Ian M. Thompson, Jr, MD, and Brian Reid, MD, PhD. At first, earlier diagnoses seemed a way for the medical community to reduce disease later on and decrease overall mortality from cancer.

But it hasn’t turned out that way, they conclude after studying cancer reports since 1975. Early diagnosis finds more of people’s cancers early on, but the data show that late-stage cancer has not dropped proportionately. In other words, early diagnosis does not necessarily save lives.

Sometimes all early diagnosis does is escalate the price of death, causing sufferers, their families, and health care teams to grasp at any therapy, even untried methods and those with little chance of success. It sometimes cruelly prolongs false hope. Treatment can be more lethal than the disease. For some physicians, it raises the specter of malpractice if they fail to explore every treatment they can think of, and it occludes the demonstrated benefits of less panicky family understanding and more beneficial palliative care.

“Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain,” illustrious Harvard surgeon and public health professor Atul Gawande confessed in a recent New Yorker article. “But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer.”

Frequently, both the medical community and the general population view cancer as an inevitable death sentence and the treatments for it as gruesome, but absolutely necessary.

“I didn’t care if it was slow growing or fast, large or small, I just wanted it out,” a New Jersey man diagnosed with early prostate cancer responded to the news. “This [reclassification] sounds like a convenient way to not treat older patients because of the costs…. They probably wouldn’t be so quick to agree with the new rhetoric.”

Dr. Anthony Horan, author of How to Avoid the Over-diagnosis and Over-treatment of Prostate Cancer, deplores the current medical approach general ignorance about cancer: “The 535 comments [within two days after the article’s publication] are familiar. There is an underlying error in many. The key fact about a given cancer is not its rate of growth, but whether it can set up ‘housekeeping’ at some distant site, i.e., metastasize.” He believes it’s necessary to stop treating every cancer as if it will immediately become aggressive and to link screening with more accurate (in many cases, longer) measurements of life expectancy.

In these days of runaway health care costs, the topic of overdiagnosis and overtreatment of cancer challenges the hearts and wallets of most Americans. The idea of reclassifying indolent cancers–those that grow slowly and are not immediately or necessarily life-threatening–raises undue alarm, the authors say. “Overdiagnosis, if not recognized, generally leads to overtreatment.”

“Some commenters seem to fear that the campaign against overdiagnosis is some sort of socialist conspiracy to reduce health care costs,” says David Isaak of Orange County, California. “In fact, many dedicated doctors and health care experts have been warning about the massive increase in unnecessary treatments for years now, and have largely been shouted down by the medical industry.”

“This [reclassification of cancer] isn’t some kind of conspiracy, it’s the way science works,” says the first commenter. “As we acquire greater understanding of medical disorders, we fine-tune our definitions of them. This is called progress. And it happens all the time with all sorts of disorders. We are constantly outgrowing categorizations.”

“Changing the language we use to diagnose various lesions is essential to give patients confidence that they don’t have to aggressively treat every finding in a scan,” lead author Dr. Laura Esserman told theTimes reporter.

“The problem for the public is you hear the word cancer, and you think you will die unless you get treated. We should reserve this term, ‘cancer,’ for those things that are highly likely to cause a problem.”

 

By Sandy Dechert for Examiner.com

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