Redefining Breast Cancer: NCI Task Force Seeks to Reduce Overtreatment
The National Cancer Institute recently completed a 16-month evaluation of our country’s cancer screening process, and how it’s led to the over-diagnosis and overtreatment of some cancers, principally breast and prostate cancer. The task force’s recommendations going forward mark a potential watershed moment in how we, as a society, view cancer.
When you hear the word “cancer” – especially if you’re older – your immediate thought is almost certainly “death.”
Decades ago, when many of us were growing up, cancer was so frequently fatal that the two words became inextricably entwined, one seldom voiced without the other.
In fact, back when cancer screening was more primitive and treatments not nearly as effective, many were fearful of even uttering the word “cancer” – referring instead to “the C word,” or “the Big C.”
But over the past four decades, since the signing of the National Cancer Act of 1971, the “War on Cancer” has made huge strides in both cancer treatment, and early diagnosis. Many cancers are no longer the automatic death sentence they used to be; and there are millions of American cancer survivors alive today, some of whom would have died from their disease a generation ago.
But those millions of survivors can be viewed two ways: as true survivors, people whose cancer would have killed them without early diagnosis and treatment; and people who were treated for a condition that, by standards currently proposed by the NCI, wouldn’t be labeled cancer – and would never have proven lethal, with or without treatment.
Hold on – isn’t cancer always a killer, if you don’t treat it?
Invasive cancer, if left untreated, will often prove fatal. But non-invasive cancer – e.g., DCIS breast cancer – may never become invasive, which is the necessary first step to being fatal.
A Norwegian study completed in 2008 indicated that up to 66% of both invasive and non-invasive breast cancers would, if left completely untreated, never become killers.
The problem is, how do you identify which cancerous cells or tumors are potential killers, and which simply benign aberrations?
Researchers are constantly refining their understanding of cancer: most importantly, how and why it progresses. How do a few atypical cells sometimes become a fatal disease – and other times remain just that, a few atypical cells? By examining cancer right down to its molecular level, scientists are beginning to understand the many paths cancer can follow over time.
And one thing is becoming increasingly clear: many of the “cancers” identified and treated today, particularly breast and prostate, are actually atypical cells that would never turn lethal. Thus, many Americans are over-diagnosed and over-treated – incurring the expense (physical, emotional, and financial) of treatment that simply isn’t necessary.
According to the NCI task force’s report, released late last month, “Use of the term ‘cancer’ should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated.” (Esserman, 2013)
The NCI recommends declassifying DCIS. “…[DCIS] should not be labeled as cancer or neoplasia, nor should the word ‘cancer’ be in the name.” (Ibid) The task force suggests naming DCIS and other benign cancers “IDLE (indolent lesions of epithelial origin).” DCIS represents about 25% of all American breast cancer diagnoses.
Support is given to this recommendation by a study recently released by the Massachusetts General Hospital Institute for Technology Assessment. The study included healthy women without a history of breast cancer, and was designed to identify any difference in patients' treatment choices based on the words used to describe DCIS.
Not surprisingly, the women who were told they had "noninvasive cancer" were more likely to choose the most aggressive treatment (surgery, vs. medication or surveillance), compared to women who were told they had a "breast lesion," or "abnormal cells." "Cancer" is clearly a highly charged word.
This first step – eliminating the word "cancer" from a DCIS diagnosis – should alleviate some of the emotional stress women diagnosed with DCIS undergo. Being told you have an “IDLE condition” feels a whole lot different than being told you have cancer.
But it’s only a first step. The task force also recommends the following: (Ibid)
Physicians, patients, and the general public must recognize that over-diagnosis is common and occurs more frequently with cancer screening. In other words, the more mammograms performed, the more IDLE conditions will be identified, the more over-treatment will occur.
Create observational registries for low malignant potential lesions. This would involve leaving DCIS untreated in women who’d agree to that course, and watching to see what happens with the condition over time.
Mitigate over-diagnosis. The NCI suggests reducing mammogram frequency; focusing screening on high-risk women; raising the threshold for mammogram recalls and biopsies; and testing “the safety and efficacy of risk-based screening approaches.” (Ibid)
Expand the concept of how to approach cancer progression. Future research should focus on environmental factors contributing to pre-cancerous conditions.
The task force concludes, “Policies that prevent or reduce the chance of over-diagnosis and avoid overtreatment are needed, while maintaining those gains by which early detection is a major contributor to decreasing mortality and locally advanced disease.” (Ibid)
Bottom line: Through further research, we need to use biology to identify which atypical cells can be classified IDLE, and which are likely to become invasive cancer. We then need to use that data to reduce the number of women diagnosed with breast cancer, and consequently treated for it.
Aggressive goals, for sure. But if the past 40 years of progress is any indication, there may be many fewer women treated for breast cancer, AND no overall increase in breast cancer mortality, far sooner than we think.
Esserman, L. (2013, July 29). Overdiagnosis and overtreatment in cancer: an opportunity for improvement. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=1722196