What Is and Is Not Cancer?

Aug 29, 2013

MESSAGE BY DR. GEORGE D.LUNDGERG, MEDSCAPE

Say 'Cancer' and You've Said a Mouthful

Hello and welcome. I am Dr. George Lundberg, at large at Medscape.

First, a disclosure: I have been a pathologist, double boarded in anatomic and clinical pathology, since 1962. I have diagnosed large numbers of cancers of very many types over that career, albeit mostly before I went into medical editing full-time in 1982.

Starting about 1965, I practiced and taught that "when you say cancer, you are saying a mouthful. Be very careful. By that diagnosis, you, the pathologist, are giving any clinician license to treat that patient and his or her cancer with whatever treatment might then be in vogue, including cutting it out, shooting ray guns at it, or poisoning the cancer and the patient."

Cancer, the Emperor of All Maladies, is on track to kill some 600,000 Americans this year, despite the miracles of modern medicine^[1]--a really big deal, a disease worthy of its fearful reputation.

Cancer cells -- anaplastic, dedifferentiated, capable of autonomous growth, utterly out of control until destroying their host -- are, however, not just one thing. We are learning more every day that cancer is many different diseases, even thousands or tens of thousands of different diseases.

For a long time, it made sense to try to eradicate all cancers, as early and as completely as possible. Mass efforts were launched to find cancers wherever they were and destroy them. Since the earliest cancers seemed to evolve from some identifiable premalignant conditions, wouldn't it make sense to also nip those in the bud? Sounds logical.

But, as with many exuberant efforts, this one got out of control. Many lesions that were called "cancer" really were not cancers at all in behavior, and this fact began to be recognized in large numbers of patients. These unfortunate victims have experienced massive psychological and physical harm and costs without any clear benefits achieved by finding and treating their "noncancers.

Call Them 'Indolentomas,' Not Cancer

Data show that unindicated mass screening and early therapy can work well with cancer of the uterine cervix^[2,3] and probably of the colon.^[4] Lung cancer screening in selected patients is too early to tell.^[5] Such approaches fail with ovary, melanoma, breast, and prostate.

Pathologists never can really predict how any one cancer will behave. But after many decades of matching histologic patterns with the natural history of diseases, we are actually pretty good at predicting which lesions will be really bad actors and which seem likely to lie around indolently.

Cure rates from aggressive therapy on those "indolentomas" are 100%. But, so would the outcomes have been of nondiscovery---100% cure of nondisease.

We all owe Laura Esserman, her colleagues, and the National Cancer Institute a great debt for recently having forcefully called this mass discrepancy of professional and public behavior to the forefront of our consciousness.^[6] Ceasing to name lesions that are most likely indolentomas by that fearsome word "cancer" is the first step. Almost any patient who hears the word "cancer" applied to their pathologic findings experiences their hair catching on fire. Even if the word is cushioned by physicians with modifiers like "in situ," "early," "precancer," "on the way towards cancer," "caught it in time," and the like, the patent simply wants to get it out of their body. A surgical sell by a surgeon becomes really easy.

Of course, even after successful name changes, many more steps must follow to tune the transition sensibly.

Will there be missteps? Certainly. Will there be resistance to change? You bet. Will there be unintended consequences? Most assuredly. Will some of those trial lawyers jump with glee at the possibility of underdiagnosis and new opportunities at lawsuits for "failure to diagnose"? Yes, but we must use our science and professionalism on behalf of the patient's best interests and collectively tell the lawyers and the hospital risk managers to take a flying leap.

Science marches on. Let's listen to it and lead from the front.

That's my opinion. I'm Dr. George Lundberg, at Large at Medscape.

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