An article in today’s New York Times (“‘Cancer’ or ‘weird cells’: which sounds deadlier?“) focuses on the question of whether many conditions currently referred to as “cancer” really are … and whether by calling them “cancer” we prejudice doctors and patients into taking overly aggressive action.
In the case of prostate cancer, identifiable forms of pathology that used to be classified as Gleason 1 + 1 = 2 through 3 + 2 = 5 until 2002 are now referred to as being Gleason 6 cancers. In other words, all pathologically identifiable forms of tissue found on a needle biopsy are now given a Gleason score of at least 3 + 3 = 6. It is the lowest assignable Gleason score for any form of “cancer” diagnosed by prostate biopsy. But are all these forms of prostate pathology really clinically significant prostate cancer? Maybe we really should be calling them something else.
In the case of breast cancer, some 20 percent of all diagnoses are now AJCC stage 0 disease (also known as “ductal carcinoma in situ” or DCIS). Is this really clinically significant breast cancer for most of the women so diagnosed?
Of course there is really no easy answer to either of these questions. At least some very early stage and apparently low risk forms of “cancer” may turn out to be aggressive. Similarly, some seemingly significant and palpable tumors may prove to be almost completely indolent.
The real problem is the same old problem … We simply can’t tell, at the time when we can now identify “weird cells,” whether those weird cells really are clinically significant or not. All that we do know is that we are certainly aggressively treating more men for prostate “cancer” and more women for breast “cancer” than really need such aggressive treatment. Why? Because the word “cancer” comes with sociocultural implications going back to a time in the late 19th and early 20th Centuries when, by the time these conditions were diagnosed and given the name “cancer,” everyone “knew” that the very diagnosis was a death sentence. Most of us still live with that perspective, despite the fact that it is demonstrably untrue.
The failure to discriminate between clinically significant and clinically insignificant forms of “cancer” also has had a secondary implication. Those men and women unlucky enough to have aggressive, clinically significant forms of prostate and breast cancers have become “marginalized.” They are no longer the only “survivors.” They have become part of a vast community of people who self-identify as “cancer survivors.” What is sad about this is that it is the people with the aggressive, clinically significant forms of progressive disease who are still most likely to die from their cancer, and who therefore are at greatest need for better treatments and greater help.
Even among the so-called “deadly” cancers — the ones like lung cancer and pancreatic cancer with 5-year survival rates of < 50 percent — we are now able to identify some “weird cells” so early that some patients ave pathologic findings that are given a different name. In the case of multiple myeloma, for example, there is a vast pool of people who are defined as having “monoclonal gammopathy of undetermined significance” (MGUS). A very small percentage of these (about 1 percent a year) do go on to have full-blown myeloma … but the vast majority don’t. They are monitored, and they are treated immediately if their condition progresses. However, these patients don’t have to live with the idea that they have a “cancer;” they aren’t clamoring to be treated; and their doctors aren’t clamoring to treat them.
Maybe there is “something” in a name?