Is now the time to rename low-risk cancers?

Everyone fears being diagnoses with cancer. The word alone sparks anxiety.

A pair of cancer specialists recently took on the topic, sharing their arguments for and against changing the language when describing low-risk tumors in a Jan. 23 viewpoint published in the BMJ.

“It is a compelling argument that ethics alone require us to use a strict definition of the word to avoid unnecessary harm to our patients—psychological, physical, and financial—from unnecessarily invasive investigation and treatment,” wrote Laura J. Esserman, MD director of the University of California San Francisco Franc Buck Breast Care Center, who was in favor of changing the terminology. “Clearly, a condition that is indolent or rarely metastasizes is not a cancer as clinically defined.”

Esserman argued that today, cancers encompass a wide range of conditions spanning high-risk tumors with a higher than 75 percent chance of progression over one to two years to those with a less than five percent chance of spreading over two decades.

Using the word ‘cancer’ not only instills unnecessary fear in patients with low-risk tumors, but removing the word when necessary can help spare many patients unneeded surgeries or invasive procedures in favor of active surveillance.

This has proved to be difficult, according to Esserman, who gave the example of eliminating radiation after lumpectomy for hormone positive, node negative tumors in postmenopausal women or Gleason 6 prostate cancers.

“Overtreating people who are not at risk of death does not improve the lives of those at highest risk,” Esserman wrote. “The refinement of the nomenclature for cancer is one of the most important steps we can take to improve the outcomes and quality of life of patients with cancer.”

The case against

In the other corner, Murali Varma, MD, with University Hospital of Wales in Cardiff, U.K., argued against changing the cancer terminology. Varma said it’s impossible to determine the course of a low-risk tumor because “excision for definitive diagnosis alters its natural course, precluding knowledge of how the tumor would have behaved if left untreated.” The uncertainty could also cause underestimation of the rate of overdiagnosis because some cancers thought to be cured wouldn’t have progressed if left untreated, he added.

Introducing new terminology to replace the word cancer may also confuse patients, Varma argued. Instead, more education should be the answer.

For example, a 5 cm papillary thyroid cancer has a substantially higher risk of metastasis compared to that of a 0.5 cm cancer. The latter is typically harmless once removed, but more dangerous if left untreated. This is similar to a bacterial pneumonia infection which is easily cured, but high-risk if left untreated, according to Varma.

“Creating new entities risks confusion, so public education about the nature of cancer must be the priority,” Varma wrote.

Categorizing some low-risk cancers as benign, and educating patients that this correlates with low-risk rather than none at all is another potential solution that would help better inform the public without adding new and confusing terms.