What is in a name? Whenever cancer is diagnosed people will immediately, and understandably become very worried. The word has certain connotations. Even though many cancers today are treatable and that many are found at an early stage, we still associate cancer with death.
This has led to the push for earlier diagnosis and screening tests. However this has caused a whole new set of problems with over diagnosis and people getting more harm from treatment than they would have experienced from the disease.
Part of the problem is that we have a view of cancer, which assumes that each one will inexorably grow and eventually lead to illness and death. The reality is that NOT all cancers that we find today will do that. Some will never grow. Some may resolve by themselves.
Yet they are all classified as cancers and thus when one is found, typically on screening, there is a push to “do something”. So if there are indeed quite different types of disease pattern, perhaps we need a different way of describing them.
To quote Otis Brawley, the chief medical officer of the American Cancer Society, “We need a 21st century definition of cancer instead of a 19th century definition of cancer, which we have been using.”
To that end a group from the National Cancer institute in the USA has recommended changing the definition of what constitutes cancer. This would also mean removing the word from certain diagnoses. We are talking about small growths which are found by chance or which may be found on screening.
The suggestion is that many lesions, which currently are called cancers, be reclassified as IDLE conditions. This stands for indolent lesions of epithelial origin. I am not a big fan of acronyms as there are already too many in medicine but this could be a good one.
Imagine the difference in how you would feel if the doctor told you that you have an IDLE condition of the breast, prostate, bowel or other body part versus cancer of the same body part? The mere use of words will significantly influence how you feel and react.
The assumption that all cancers grow and every early stage cancer will develop led to the early diagnosis push and mass screenings. As I have written previously there was no testing of screening in the way that pharmaceuticals or even new surgical procedures are trialed. They were just introduced and worse than that, heavily promoted. People are almost railroaded into having screening tests and made to feel guilty if they decline.
Now with 30 years of evidence we know that many cancers do NOT develop. Some 70% of 70-year-old men have prostate cancer at time of death but it was NOT the cancer, which killed them, nor would it have. We know that up to 40% of lesions found on screening mammograms are ductal carcinomas in situ, most of which will never grow or become cancerous. We also know that despite a near doubling of detection and treatment of early stage cancer (in the USA) over 30 years there has been only a tiny percentage drop in diagnosis of late stage cancer. Hence we are finding and treating cancers, which would NOT have developed.
But it not surprising that when all cancers are labeled the same that all will be treated the same.
The point is that medical knowledge evolves. We do not use leaches any more. The fact that we had a view on screening and diagnosis in the 1970’s does not mean that we have to hold the same view today.
Indeed much of what we hold to be true in medicine is not necessarily so. Just last month a major review cast doubt on many trials using animal models. The number of positive trials was way more than would be expected. In turn only eight out of 160 treatments should have been tested in humans. This reflects a mix of fraud, bias and incentive to get positive results.
A review published in the Mayo Clinic proceedings showed that over 40% of the established practices in medicine (which were studied for the review) were ineffective or harmful! Some 38% were useful and in 22% it was unknown. In many instances “new” practices were no better or worse than ones superseded!
With that in mind it should not come as a surprise that our approach to cancer diagnosis may now be shown to be wrong even if it seemed right some years ago. We can only ever go with knowledge available at the time.
However there will be enormous resistance to winding back needless screening as empires, reputations and big dollars are involved. Many doctors, screening agencies, advocacy groups and even some charities, will not welcome inconvenient facts.
Nevertheless we are in the 21st not the 19th century. It is time to learn from our experiences over the last 30 years where good intentions have led to much harm along with some good.
It is time to evolve our approach to screening for, and diagnosis of cancer