Recently, a working group of experts who advise the National Cancer Institute (NCI), comprising some of the top scientists in cancer research, proposed that the terminology of some early-stage, noninvasive forms of cancer, such as ductal carcinoma in situ (DCIS), be changed.
Currently, DCIS is considered the earliest form of breast cancer, and the experts recommend it be reclassified as indolent lesions of epithelial origin (IDLE).1
In some ways, I can understand the change in nomenclature. Breast cancer, even in its earliest stage can create a roller coaster of emotional responses. And, it is suggested that a change in name may help to decrease unnecessary treatments.2 The fundamental problem with the term "cancer" when it is attached to a possibly premalignant condition is that the patient -- and often the physician -- think that cancer is cancer and that something must be done.
Ian M. Thompson Jr., MD, Director of the Cancer Therapy & Research Center at the University of Texas Health Science Center, San Antonio states2:
Many precancerous conditions have a very low risk of progressing to cancer and, even if cancer develops, it may have a very low risk of causing harm in the patient's lifetime. What needs to be done is to assign a very precise word that is linked directly with the risk of the condition. The word cancer often has a very bad connotation.
Early diagnosis has not led to a proportional decline in serious disease and death. Instead, current screening programs identify, not only malignant cancers, but also slow-growing, low-risk lesions and combine them into the same treatment process. Dr. Thompson and his colleagues suggest this is leading to overdiagnosing and overtreating of some forms of cancer that might never actually cause harm to an individual.2, 3
The new recommendations include recognizing that screening will identify indolent cancer, changing terminology, and omitting the word “cancer” from premalignant/indolent conditions. The recommendations also include convening a multidisciplinary body to revise the current taxonomy of cancer and to create reclassification criteria for indolent conditions. In addition, the authors propose creating observational registries for lesions with low potential for malignancy.
Richard L. Schilsky, MD, who is the Chief Medical Officer for the American Society of Clinical Oncology (ASCO), said he generally agrees with most of the recommendations put forth in the JAMA article1:
The essence is to recognize that cancer is very heterogeneous in its clinical presentation and course and that people are very heterogeneous in their risk of developing cancer. The authors advocate for "risk-adapted" screening. I agree with this approach.
This proposed change in name has me somewhat confused and concerned. Would patients or their clinicians be more complacent about screening or diagnostic workups if there was a perceived “low risk” of advancing disease? Do we have the genomic nature of breast cancer understood well enough to accurately diagnose which lesions are indolent and which are more aggressive? And finally, how can we take decades of public health education and shift the paradigm so that patients and their clinicians are comfortable in delaying action on what was previously known as “early stage cancer”? Stay tuned.
What are your thoughts on changing the name?
Esserman LJ, Thompson IM, Reid B. Overdiagnosis and Overtreatment in Cancer: An Opportunity for Improvement. JAMA. July 29, 2013
John Schieszer, MA ChemotherapyAdvisor.com. August 22, 2013
Vidali C, Caffo O, Aristei C, Bertoni F, Bonetta A, Guenzi M, Lotti C, Leonardi MC, Mussari S, Neri S, Pietta N. Conservative treatment of breast ductal carcinoma in situ: results of an Italian multi-institutional retrospective study. Radiation Oncology 7:177. Oct. 25, 2012
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