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Mark A. Hurt MD

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[color=#000000][font=Arial, sans-serif][size=3]“What's in a name? that which we call a rose by any other name would smell as sweet;”

-- Shakespeare (Romeo and Juliet, Act II, Scene 2. Published 1597)


Is Cancer [i]Cancer[/i]?

What is cancer? Those reading this blog are in the cancer “business.” Cancer is a neoplasm (a stimulus independent cellular proliferation) that, untreated, has the capacity to kill the patient. As a rule, this is the meaning of malignancy when applied to cellular proliferations. We diagnose cancers by identifying their histopathological characteristics, correlating the context, and applying a name, e.g., squamous cell carcinoma, basal cell carcinoma, Merkel cell carcinoma, etc. Those names imply a range of clinical outcomes that depend on a variety of factors: context of the lesion, depth, location anatomically in relation to vital structures (e.g., an orbit, nerves, blood vessels). Those outcomes depend also on somewhat nebulous factors not identified on any glass slide: age, location, immune status, tumor burden, etc.

Are we doing our patients a disservice by doing this? When we apply such a name to a cellular proliferation and consider it to be under the umbrella of cancer, is this bad information for them? Should we play “nice” and not use such a term in order not to hurt someone's feelings or cause undue anxiety?

These are questions that deserve straightforward answers, as patients’ lives depend on them.

Thus, I take serious issue with a recent article, published in [i]Lancet Oncology[/i], by Esserman et al., and titled “Addressing overdiagnosis and overtreatment in cancer: a prescription for change.”

In their abstract, the authors make this amazing statement:[/size][/font][/color]

[indent=1]“We propose the term indolent lesion of epithelial origin, or IDLE, for those lesions (currently labelled as cancers) and their precursors that are unlikely to cause harm if they are left untreated.”[/indent]

Yet, we already [i]have[/i] a name for them: benign neoplasms. Benign neoplasms cause harm only by [i]happening[/i] to impinge on vital structures, which has been referred to as “malignant by position.” Otherwise they have no capacity to kill the patient.

But this is [i]not[/i] what the authors mean. They mean, by the acronym “IDLE,” the following:

[indent=1]“Furthermore, precursors of cancer or high-risk disorders should not have the term cancer in them. The rationale for this change in approach is that indolent lesions with low malignant potential are common, and screening brings indolent lesions and their precursors to clinical attention, which leads to overdiagnosis and, if unrecognised, possible overtreatment.”[/indent]

The authors here make a common equivocation; they assume that a “precursor” of cancer or “high risk” disorders are valid ideas — which they aren't. Presumably, according to this point of view, a “precursor” lesion or a “high risk” lesion isn't itself cancer if the statistics show the outcome of the lesion to be slow growing or cured if treated.

To what kind of cutaneous lesions do the authors refer? — basal cell carcinoma and squamous cell carcinoma, to wit:

[indent=1]“About 2·2 million predominantly older (>65 years) Americans are diagnosed with non-melanoma skin cancers every year, including basal-cell and squamous-cell cancers. The number diagnosed and given aggressive treatment has risen by more than 50% in the past decade. Except in some small, immunosuppressed populations, basal-cell and squamous-cell carcinoma are rarely fatal. If left untreated (for years), they can cause local problems, some serious. Despite less invasive treatment options being available, the proportion of aggressive surgical procedures done in patients with limited life expectancy is almost the same as in healthy individuals. Non-melanotic skin cancer is a candidate for change in terminology to promote safe alternatives to large excision or Mohs’ surgery, such as observation.”[/indent]

So, observation of these cancers is an acceptable treatment for patients with “limited life expectancy?” This, despite the curious admission that “If left untreated (for years), they can cause local problems, some serious.” And [i]this[/i] is the reason for declaring that cancer is not cancer. I ask, "by what standard?" Whatever happened to the doctor-patient relationship and the tailor-making of treatments to fit the patient's medical condition in the context of his own life with his own, individual, life as the standard?

In my opinion, this is the worst example of context dropping I have witnessed in my 32 years of pathology practice.

-----

I admit, however, that I agree — in part — with the authors about so-called “atypical” melanocytic nevi. They state their position as follows:

[indent=1]“Thousands of atypical naevi are excised every year, but little to no evidence exists to show that any dysplastic naevi evolve into melanoma. When dermatologists self-refer pathology, their biopsy rates increase by 30% per year. Solutions include reassessment of precursor lesions (eg, dysplastic naevi) for their consequential cancer potential and the use of computer-aided diagnostic methods to set better thresholds for biopsy. Efforts have been made to establish an expert panel to identify solutions (including changes in terminology) to reduce benign biopsy rates and overly aggressive procedures.”[/indent]

The context is different with melanocytic nevi (I reject the term “dysplastic”). Of course they are correct about these nevi — but the whole point of the terminology of a nevus is just that: it's a nevus, and it is not a “precursor” of anything malignant, is not melanoma as such, and it never will be. This is not true of basal cell carcinomas or squamous cell carcinomas. They are cancers. Their natural history, if allowed to play out, is the capacity to kill the patient.

This is why the acronym “IDLE” should be rejected, if not out of hand, then after only a short consideration of the obvious contradiction these authors hope for the medical community to accept.

I don't and won't accept it. I think it's a matter of life or death.




Reference:

Esserman LJ, Thompson IM, Reid B, Nelson P, Ransohoff DF, Welch HG, Hwang S, Berry DA, Kinzler KW, Black WC, Bissell M, Parnes H, Srivastava S. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol. 2014; 15(6):e234-42. doi: 10.1016/S1470-2045(13)70598-9. PubMed PMID: 24807866.
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