Tumors that are unlikely to cause serious health issues should be reclassified as non-cancers, a proposal that was made back in 2012 when the National Cancer Institute (NCI) convened a conference to discuss the overdiagnosis and overtreatment of indolent tumors—asymptomatic lesions unlikely to progress for years—that are detected by mammography, prostate-specific antigen (PSA) testing, and other screening tools.
The meeting participants’ first recommendation was to remove the word cancer from the names of tumors unlikely to become a problem. Instead, the participants urged, the tumors should be classified as indolent lesions of epithelial origin or IDLEs. Their reasoning? The word cancer generates fear and anxiety, which leads to overdiagnosis and, if unrecognized, possible overtreatment of tumors that are almost never associated with invasion and disease progression.
The word “cancer” is attributed to Hippocrates 2,500 years ago, though the disease was described by the Egyptians 2,500 years earlier. Then tumors could be seen or felt. Today, we also identify cancer based on blood samples, biopsies or surgically removed specimens meeting specific criteria under the microscope. But as newer and more sensitive technologies come into use, we are increasingly identifying medical conditions that might have gone undetected without any issues.
Most experts agree that no matter what low-risk tumors are called, patients in whom they’re detected need better information about their diagnosis before deciding how to proceed. In other words, stop calling low-risk tumors cancer, but make sure patients understand that such lesions are risk factors for cancer and, therefore, require diligent monitoring. Or keep calling the tumors cancer, but make sure patients understand that these lesions are unlikely to cause problems, so active surveillance, not immediate treatment, is appropriate. (1)
Let’s look at three examples. For prostate cancer, a biopsy showing a grade of Gleason 6 (also known as Grade Group 1 or GG1) is considered low or very low risk. Recent discussions have challenged whether GG1 should be labeled “cancer” due to its indolent nature and noted that it “is so highly prevalent it might be considered a normal feature of aging.” (2) For individuals with GG1 biopsies, the joint guideline from the American Urological Association (AUA) and American Society for Radiation Oncology (ASTRO) recommend active surveillance as the preferred management option. A 2022 article called reclassifying Gleason 6 prostate cancer as not cancer a “flawed” idea. (3)
In breast cancer, diagnosis of ductal carcinoma in situ, or D.C.I.S., is similarly low or very low risk, indicating the very earliest, noninvasive stage of the disease. These findings make up about 20 percent to 25 percent of breast cancer diagnoses in the United States, involving about 100,000 people annually. These patients are routinely treated with surgery or radiation, even though their conditions are not life threatening and cause no symptoms at the time they are spotted. Studies have shown that the cause-specific survival rate of patients with DCIS is 97% or 98%, raising the possibility that a similarly high survival rate could be obtained with a less-aggressive approach like active surveillance. (4)
While the debate over reclassifying DCIS and GG1 prostate cancer as not cancer has bubbled for years, the relabeling of one noninvasive thyroid tumor happened relatively quickly. (5) The tumor in question was called encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC). Although evidence was growing that EFVPTC was unlikely to become invasive, it usually was treated the same as conventional thyroid cancer, with a complete thyroidectomy and radioactive iodine to destroy any remaining thyroid tissue. Patients then needed thyroid hormone replacement therapy for the rest of their lives. An international team of authors called for renaming noninvasive EFVPTC as noninvasive follicular thyroid neoplasm with papillary-like nuclear features, or NIFTP. And in 2017, the World Health Organization recognized NIFTP as a new term. (6)
Renaming very low-risk cancers would make it easier to persuade patients when it’s appropriate to adopt monitoring and risk reduction as their approach. Clinical trials are obviously the way to change the field. Some in the medical community argue that early-stage cancer patients may have regions of their prostate or breast with unsampled, riskier cancers that may pose a threat and should be treated accordingly. But it should not be routine, as it is now, to treat based on what might have been missed. There are many tools at our disposal to accurately diagnose patients. We should use them in order to reduce unnecessary treatments and their side effects and improve screening, prevention and care.
