Rethinking Cancer Diagnosis and Treatment
In 2012, the National Cancer Institute (NCI) convened a working group to explore the overdiagnosis of cancer, which often leads to the overtreatment of cancer.
Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN
Editor-in-Chief OncLive Nursing
Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing Louisiana State Health Sciences Center in New Orleans, Louisiana
In 2012, the National Cancer Institute (NCI) convened a working group to explore the overdiagnosis of cancer, which often leads to the overtreatment of cancer. The group recognized that public awareness of early detection and improved cancer screening have increased the likelihood of identifying cancers that do not become clinically apparent and are not life threatening.
Policies that prevent or reduce the chance of overdiagnosis and overtreatment are needed, and the NCI group proposed that the term “cancer” be redefined and, in some cases, eliminated. For instance, ductal carcinoma in situ, which clinicians now recognize is not cancer, should be renamed to exclude the word carcinoma. The group also suggested that many lesions detected during breast, prostate, thyroid, lung, and other cancer screenings should not be called cancer and instead be reclassified as IDLE conditions or “indolent lesions of epithelial origin.”
The NCI group recommended that fewer unnecessary screenings be performed and that patients should only be diagnosed with cancer when lesions/tumors are lethal and require immediate treatment. Also needed are better methods to recognize and monitor indolent and non-aggressive lesions/tumors.
Historically, clinicians recommended—and patients demanded—aggressive treatment of all types of cancer.
We now know that some types of cancer, when left alone, will never grow, spread, or harm the patient. The question then becomes, who should be watched and who should be treated? Much of the research in this area has focused on the treatment of prostate cancer and breast cancer.
Prostate and Breast Cancer Studies
The 2013 Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) randomized 695 men who had early prostate cancer to either treatment with surgery or watchful waiting with no initial treatment (N Engl J Med. 2014; 370(10):932-942). In the surgery group, 63 deaths were due to prostate cancer, and in the watchful waiting group, 99 of the deaths were due to prostate cancer. The researchers noted that surgery reduces the risk of dying from prostate cancer by 44%, but as they looked closer at different groups, what emerged was that this does not apply to all patients. Surgery improved outcomes for men diagnosed at a younger age or with intermediate-risk disease. Thus, patients must individually assess the risks of surgery and weigh the possible benefits, and consider factors such as age, comorbidities, and overall quality of life.
Study findings presented at the 2013 San Antonio Breast Cancer Symposium (SABCS) similarly noted that certain groups of women with breast cancer may be able to safely forgo treatment or receive less treatment (Abstract S2-02). A study conducted in Mumbai, India, randomized 350 women with large breast cancers that had shrunk after initial chemotherapy to receive no further treatment and half to receive surgery (mastectomy or lumpectomy and node dissection). After 2 years, 40% of both groups were alive, which suggests that chemotherapy alone is enough.
In another study presented at SABCS, 1326 women 65 years or older with early-stage, hormone-positive breast cancers were randomized to receive radiation therapy or not receive radiation therapy. After 5 years, 96% of both groups were alive, and most of the deaths that occurred did not occur from breast cancer (Abstract S2-01).
Only 1% of women given radiation therapy had cancer recur in the treated breast versus 4% of those who did not receive radiation therapy. The researchers concluded that for every 100 women treated with radiation, one will have a recurrence anyway, four will have a recurrence prevented, and 95 will have received unnecessary treatment.
We are entering an era of “less is more” treatment, and treatment decisions are increasingly being individualized to the patient and not the type of cancer or stage of disease. Patients are becoming more sophisticated consumers as well, thanks in part to the massive amount of information that is publicly available.
Patients now are better informed about the success of lesser treatment or no treatment of certain cancers and conditions. Increasingly, patients want to know what is the best treatment—not the most aggressive treatment—and want to know what is best for them as an individual.