Cancer Semantics Helping Resolve Overdiagnosis and Overtreatment (9/10/13 issue)
I read both the JAMA “Overdiagnosis and Overtreatment in Cancer: An Opportunity for Improvement” article and the related OT news article evaluating the semantics of cancer (9/10/13 issue) with interest. I compliment the authors of the JAMA paper for their leadership.
I fully concur with the comments that cancer diagnosis should be based on cell/tumor behavior rather than on cells' morphological appearance under the microscope. Similarly, the problem is not screening, but rather treatment of the appropriate cancer and patient.
Physicians who are proponents of no screening for prostate cancer after the age of 70 would agree that these patients with Gleason scores of 8, 9, 10 benefit from early treatment. Yet how does one diagnose early-stage, high-grade prostate cancer without screening? Clearly an ostrich-like approach of “burying the head in the sand” (no screening) is not the solution.
Rather than argue about screening or cancer nomenclature, efforts would be better served if the medical establishment adopted a scoring system using a weighted point scale to select the need for treatment and perhaps the type of treatment recommendations. In the case of prostate cancer, the criteria would include clinical stage, Gleason score (and other pathological descriptors), absolute PSA level, PSA velocity, race, family history, patient age, and co-morbidities.
I have not read a single paper that recommends ignoring high-grade DCIS of the breast. With surgical excision alone, the 10-year local recurrence rate for high-grade DCIS is 27 percent and a 10-year risk for invasive cancer of 19 percent (ECOG 5194 data). This behavior certainly does not fit into IDLE (indolent lesions of epithelial origin), and does not warrant benign neglect (no treatment beyond surgical excision).
A point scoring system for various types of cancers would be a big step to routine “personalized cancer treatment,” and at some point may even incorporate the patient's and tumor's genomic data. If the threshold score for treatment is already reached, no further markers or test(s) may be needed—for example: in breast cancer, the presence of nodal disease obviates the need for Oncotype DX testing.
With the widespread availability of multi-factorial computing facility, a weighted scoring system for various indolent and other types of cancers may be a step forward to determine need for treatment, patient prognosis, and to compare effectiveness of various treatment options. And, be a true “Opportunity for Improvement” with less controversy, more science, and widespread acceptance by oncologists, non-oncologists, patients and payors (insurance carriers).
GILBERT A. LAWRENCE, MD, DMRT, FRCR
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