Should we rename some low-risk cancers?

Cancer by any other name is still cancer, but should we rename some low-risk or indolent ones in a bid to reduce anxiety and even potential harm from unnecessary investigation and treatment?

That’s a question medical journal The BMJ put to two experts, and their responses do much to fuel a lively discussion.

Arguing firmly for the affirmative is Laura Esserman, director of the Carol Franc Buck Breast Care Centre in San Francisco in the US.

She says that while the clinical definition of cancer remains of a disease that if untreated will grow relentlessly and spread to other organs, killing the host, today we routinely use the word to describe diseases that may have as little as a 5% chance of progression over two decades.

And because modern screening programs are detecting more such ultra-low-risk cancers – including, she suggests, many thyroid, prostate and breast cancers – we’re seeing more investigation and invasive surgery, which themselves carry risk and can lead to a lifetime of anxiety.

Rather than surgery, Esserman suggests, we should in some situations offer active surveillance, but “it is difficult to encourage patients to wait and watch once they have been told they have cancer”.

Overtreating people who are not at risk of death “does not improve the lives of those at highest risk,” she writes. “The refinement of the nomenclature for cancer is one of the most important steps we can take to improve the outcomes and quality of life of patients with cancer.”

Not so, says Murali Varma, at doctor at the University Hospital of Wales in Cardiff, who warns that creating new entities risks confusion.

In practice, it is impossible to determine the natural course of any low risk tumour, he says, “because excision for definitive diagnosis alters its natural course, precluding knowledge of how the tumour would have behaved if left untreated”.

This uncertainty could also lead to underestimation of the frequency of overdiagnosis as some “cured cancers” would not have progressed even if untreated, he adds.

Varma believes that, rather than focusing on semantics, the key is to educate everyone from the healthy public to health professionals about the meaning of a diagnosis of cancer.

New terminology often leads to confusion, so an alternative approach would be to recalibrate thresholds for the diagnosis of cancer, so that some very low-risk cancers are categorised as benign, he suggests.

“If the public were educated that benign signifies very low risk rather than no risk at all, then anxiety inducing labels could be avoided,” he concludes.

You can read both arguments in full here, along with a patient commentary here by Birte Twisselmann, an editor at The BMJ, who describes the “considerable worry” of having two suspicious lesions dealt with in less than a year.

Despite their low risk, she says the “confusing terminology for cancers and precancerous lesions made me anxious”.