“How could they see anything but the shadows if they were never allowed to move their heads?”
— Plato, The Allegory of the Cave
My articles on cancer over the years have been stressing one important truth that many of the so-called early cancers are not cancer at all. My friends and, even some of my old students, have been upset and cursing me. On July 27, a group of scientists from the National Cancer Institute published its finding after a meeting where it seemed to have discovered that truth that had dawned on me decades ago making me an object of ridicule in the eyes of my colleagues.
These scientists recommendations were published in The Journal of the American Medical Association. Some pre-malignant conditions, like the one that affects the breast called ductal carcinoma in situ, they feel, should be renamed to exclude the word “carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.” They also suggested that many of the lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should be reclassified as “indolent lesions of epithelial origin.”
“We need a 21stcentury definition of cancer instead of a 19thcentury definition of cancer, which is what we’ve been using,” said Dr. Otis W. Brawley, chief medical officer for the American Cancer Society. The impetus for this call for change must have come from the growing concern of some doctors, scientists and patient advocates that millions of men and women are “undergoing needless and sometimes disfiguring and harmful treatments for pre-malignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.”
The recent routine screening using modern gadgets has increased cancer diagnosis so much that over diagnosis and overtreatment causing misery for millions are so common meriting urgent action. “We’re still having trouble convincing people that the things that get found as a consequence of mammography and P.S.A. testing and other screening devices are not always malignancies in the classical sense that will kill you,” said Dr. Harold Varmus, Nobel Prize-winning director of the National Cancer Institute. “Just as the general public is catching up to this idea, there are scientists who are catching up, too.”
“Ductal carcinoma in situ is not cancer, so why are we calling it cancer?” asked Dr. Esserman, who is a professor of surgery and radiology at the University of California, San Francisco. The demand for changing the name of cancer has precedents. The World Health Organisation in 1998 changed the name of an early-stage urinary tract tumour, removing the word “carcinoma” and calling it “papillary urothelial neoplasm of low malignant potential.”
“Changing the language we use to diagnose various lesions is essential to give patients confidence that they don’t have to aggressively treat every finding in a scan,” Dr. Erasmus said. She went on: “The problem for the public is you hear the word cancer, and you think you will die unless you get treated. We should reserve this term ‘cancer’ for those things that are highly likely to cause a problem.”
Today doctors are finding and treating scores of seemingly precancerous lesions and early-stage cancers — like ductal carcinoma in situ, a condition called Barrett’s oesophagus, small thyroid tumours and early prostate cancer. But even after aggressively treating those conditions for years, there has not been a commensurate reduction in invasive cancer, suggesting that overdiagnosis and overtreatment are occurring on a large scale.
“This is a long way from the thinking 20 years ago when you found a cancer cell and felt you had a tremendous risk of dying,” Dr. Varmus said. We have come a long way from the 19h century diagnosis. We need a new 21st century diagnosis where only aggressively growing cancers need symptomatic treatment. This boils down to what I have been saying about any disease in general. “Patient doing well-do not interfere” was William Osler’s famous advice in 1905 AD. I think he is right even today. Pre-cancer, pre-diabetes, pre-hypertension and such fancy ideas have resulted in millions undergoing treatment when it is not needed and might be even dangerous.
In the pre-symptomatic stage, no disease could benefit from outside intervention as the immune system is trying its best to correct the problem. It is only in the unlikely event of the immune system getting overpowered do symptoms arise. That is when we, doctors, do come into the picture to “cure rarely, comfort mostly but to console always.”
“Education leads to enlightenment. Enlightenment opens the way to empathy. Empathy foreshadows reform.”
Derrick A. Bell, Faces At The Bottom Of The Well.
(The writer is a former professor
of Cardiology, Middlesex Medical School, London, and
former Vice-Chancellor, Manipal University. Email: firstname.lastname@example.org)