Don’t call low risk lesions cancer, experts say

BMJ 2013; 347 doi: (Published 02 August 2013) Cite this as: BMJ 2013;347:f4909
  1. Michael McCarthy
  1. 1Seattle

Calling low risk lesions something other than cancer would be one element of a new approach to cancer screening proposed by a working group convened by the US National Cancer Institute to look into the problem of cancer overdiagnosis and overtreatment.

The group’s findings are outlined in a viewpoint published by the Journal of the American Medical Association (JAMA). Laura Esserman, of the University of California, San Francisco, was the article’s lead author.1

Esserman and her coauthors noted that over the past 30 years, the goal of cancer screening had been to reduce the rate of cancer deaths by diagnosing the disease early. However, despite an increase in the diagnosis of early stage disease, there had not been a “proportional decline in later stage disease” overall.

They said that screening for breast cancer and prostate cancer, for instance, appeared to lead to the diagnosis of more cancers that will prove to be clinically insignificant, while detection and removal of precancerous lesions, such as Barrett esophagus and ductal carcinoma of the breast, had not reduced the incidence of invasive cancer.

The problem is that the biology of cancer is complex. The panelists said, “The word ‘cancer’ often invokes the specter of an inexorably lethal process; however, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime.”

They added that a better understanding of the biology of cancer would be needed to design better screening programs, as would improved molecular diagnostics capable of determining which cancers were likely to be aggressive and which indolent.

The group drew up five recommendations for going forward.

First, they called on physicians, patients, and the general public to recognize that overdiagnosis was common.

Second, they urged that the term “cancer” only be used to describe lesions that had a “reasonable likelihood of lethal progression” if not treated. “Premalignant conditions (eg, ductal carcinoma in situ or high grade prostatic intraepithelial neoplasia) should not be labeled as cancers or neoplasia, nor should the word ‘cancer’ be in the name,” they said. Instead, such cancers should be reclassified “as IDLE (indolent lesions of epithelial origin) conditions.”

Third, observational registries should be created to improve our understanding of lesions thought to have low malignant potential. The authors said, “Large registries for potentially indolent conditions would provide data linking disease dynamics (eg, tumor growth rate over time) and diagnostics needed to provide patients and physicians with confidence to select less invasive interventions.”

Fourth, they noted, strategies needed to be developed to reduce the detection of indolent diseases, such as reducing the frequency of screenings, for example, focusing screening on high risk populations, or raising the thresholds for recall and biopsy.

And finally, research was needed to develop ways to slow or halt progression of precancerous and cancerous lesions as an alternative to surgical excision.

The group concluded, “Physicians and patients should engage in open discussion about these complex issues. The media should better understand and communicate the message so that as a community the approach to screening can be improved.”


Cite this as: BMJ 2013;347:f4909


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