Panel: Cancer screening, treatment need major update

A group of scientists that includes a urologist is proposing a major update of the way the U.S. approaches diseases now classified as “cancer,” including eliminating that term from tumors considered indolent.

When cancer screening programs, including those for prostate cancer, were widely initiated 3 decades ago, medical knowledge of the disease was more simplistic. The intent was to detect cancer at its earliest stages to reduce illness and mortality, but in fact early diagnosis has not led to a proportional decline in serious disease and death, the scientists wrote online in JAMA (July 29, 2013).

Instead, screening programs are identifying not only malignant cancers, but also slow-growing, low-risk lesions, and sweeping them into the same treatment process. As a result, patients are being diagnosed and treated for forms of cancer that might never actually harm them. Overdiagnosis is particularly common in cancers of the prostate, breast, lung, and thyroid cancer, as well as melanoma, said the authors.

Now, with the advancement of scientific understanding of the biology of cancer, the authors say it is time for significant changes in practice and policy.

“By recognizing that cancer is not one disease, but a number of different diseases, we can individualize our treatment based on biology and avoid overtreatment,” said panel chair Laura J. Esserman, MD, MBA, of the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center.

The authors, who also include urologist Ian M. Thompson, MD, of the University of Texas Health Science Center at San Antonio, recommend creation of a new classification for tumors that are indolent. For example, ductal carcinoma of the breast (DCIS) would no longer be called cancer. The authors also call for the formation of registries for lesions with low potential for malignancy and for a multidisciplinary approach across pathology, imaging, surgery, and other medical specialties “to revise the taxonomy of lesions now called cancer.”

The key, they say, is to improve screening strategies to avoid overtreating tumors that would not be lethal, or that would not even have come to medical attention.

The article is comprised of recommendations from a working group formed last year during a meeting convened by the National Cancer Institute. The group was charged with developing a strategy to improve current approaches to cancer screening and prevention. The commentary was co-written by Dr. Esserman, Dr. Thompson, and Brian Reid, MD, PhD, of the Fred Hutchinson Cancer Research Center in Seattle. The three authors served as chairs of the NCI working group.

The recommendations include:

• Recognize that screening will identify indolent cancers.

• Change terminology and omit the word “cancer” from premalignant/indolent conditions.

• Convene a multidisciplinary body to revise the current taxonomy of cancer and to create reclassification criteria for indolent conditions.

“The ultimate goal is to preferentially detect consequential cancer while avoiding detection of inconsequential disease,” the authors wrote.

To get weekly news from the leading news source for urologists, subscribe to the Urology Times eNews.