Report suggests changes in the definition of what is cancer

Here's a link to a story in today's New York Times

well.blogs.nytimes.com/2013/07/29/report-suggests-sweeping-changes-to-cancer-detection-and-treatment/?hp&_r=0

Here's a brief quote:
The group, which includes some of the top scientists in cancer research, also suggested that many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should instead be reclassified as IDLE conditions, which stands for “indolent lesions of epithelial origin.”

We should expect that some men are going to remain satisfied with our 19 th century definition of “cancer” which is in use today while others are going to be concerned about someone other then themselves…such as the “next guy through the PC door.” Knowing what we know about low-risk prostate cancer, I’m baffled that this hasn’t been done, implemented, and moved-on…but, change takes time:   “We’re still having trouble convincing people that the things that get found as a consequence of … P.S.A. testing and other screening devices are not always malignancies in the classical sense that will kill you,” said Dr. Harold Varmus, the Nobel Prize-winning director of the National Cancer Institute. “Just as the general public is catching up to this idea, there are scientists who are catching up, too.”      

In a recent poll here 70% thought low risk Gleason 6 should be labeled "cancer."

Is the "cancer" label appropriate for Gleason 6/low risk?

Of course, almost everyone on this site has gone through radical treatment, so perhaps we are seeing this issue through confirmation bias.

I agree that it's an important question, with many implications. A lot depends on one's definition of the word cancer:

• Unconstrained cellular division?
• Capable of metastasis?
• Capable of invading other organs?
• Dysplasic cells?
• Less differentiated cells?
• Immortal cells?

I personally don't believe that Gleason Grades 1-3 are cancerous, and certainly PIN is not. Gleason grades indicate the degree of dysplasia. While the degree of dysplasia is correlated with other indicators of malignancy, it appears that a certain minimum amount of dysplasia is required. The dysplasia shown in Gleason grades 1 & 2 are considered so unimportant as to no longer merit being reported by pathologists. Perhaps it's time to add Gleason scores of 3+3 to the list of pre-malignant conditions that we watch but don't treat.

- Allen

(edit: misspelled dysplasia)

Post Edited (Tall Allen) : 7/29/2013 12:49:38 PM (GMT-6)

It seems to me that nearly everyone would agree that there is SOME deviation from a "normal" cell pattern that is close to the line, between being properly called "cancer" and "not cancer." Say, just for example, a diagnosed Gleason 5 (3+2), where reasonable pathologists could differ as to whether the Gleason 2 should be a 3.

Given that there are necessarily close calls, and that there are consequences both for over-diagnosis and for under-diagnosis, the idea that doctors are struggling with exactly where to draw the line between "cancer" and "not cancer" does not seem, to me, to be at all surprising.

I guess if I thought scientists or doctors were suggesting a possible change because they want to kill patients or trick people who have cancer into thinking that the do not have cancer, then it would be -- to say the least -- very controversial. But I personally do not believe any such thing.

I guess my personal opinion that Cancer is Cancer takes me off the list of respected moderators. But I firmly believe that reducing what is called cancer simply leaves more men open to underdiagnosis and undertreatment. Having seen a good friend die of undiagnosed (until the bitter end) PCa in the pre-PSA era, I will never be moved from my position.

By anyone, here or elsewhere.

EDIT:  Thanks, Tud, for deleting logoslidat’s inappropriate ad hominem attacks…there is no place for that here, and it warrants prompt & direct action such as yours. Post deleted...Casey, I deleted the post to which you were referring so your response was unnecessary. Post Edited (Tudpock18) : 7/29/2013 12:20:08 PM (GMT-6) Post Edited (Casey59) : 7/30/2013 9:35:15 AM (GMT-6)

Casey, I did read the article, and the quote may have been copied correctly, but I find it to be of little or no value. How many things were invented discovered thousands of years ago that are still valid? The wheel? Gravity? I hope age does not become an automatic disqualification for existence. My opinion is based on my experience, and I would hope it could be respected as a meaningful, intelligent point of view, following the rules of the forum.

Thats hilarious Casey, I read the article completely as well as your post and aimed my " shot " {your word} directly at you, something you failed to do in your response. You actually should think about my response, and you will, as it is intended to hone your advocate skills. An intelligent and meaningful person as you will recognize this and proceed accordingly. No sarcasm intended. Re read your first post on this thread, could you not see your wording as provocative. If you do that with your peers here, then trust me you will do that with your peers in other ares of your advocacy. Most people will not tell you, you have bad breath. I assuredly will.

heretofore. Not a semanticist, but here=now, to=going fore=fore as in foreword, not former. Could be wrong, but context, like love, covers a multitude of sins.

This is one of those arguments that nobody should be happy winning. In advocating a change to the terminology by which certain low-risk "cancers" are described we are trying to change the behavior of men who have been diagnosed with them. If the idea is not to change their behavior then there is no point changing the terminology because changing the name won't change the disease itself, just how we react to it.

Presumably the terminology change is being suggested in hopes of stemming the tide of men who, panicked by the word cancer rush willy-nilly to treatment options that cause them more problems than the cancer ever would. By statistical measures we can demonstrate that such men exist in large numbers and if the desired change in behavior is in fact realized then many men would be spared the side effects of treatment -- side effects of which we are all too, too familiar.

Balanced against that is the likelihood that there will be men diagnosed with this newly less-alarming cancer who will be lulled into a false sense of security and will not be vigilant in monitoring their disease while it progresses, or while it manifests the fact that it was actually a more-virulent cancer misdiagnosed as low-risk. Some of those men will miss their opportunity for a cure and a small number of them will die.

So as I see it we are left with two tragic choices -- more men maimed to save a few from a painful and undignified death vs fewer men suffering from treatment side effects with progression in a few higher-risk cases that current technology can't reliably exclude. I can't see being particularly happy about either option. The only thing that might be worse than losing the argument is to win it -- and have to take ownership of the downside.

Logoslidat said...
Tall Allen do you believe that gleason 6 can turn into a more aggressive disease and if so , should folks have the choice to nip it in the bud, given that they are aware of the S/E.

I'll repeat what I wrote elsewhere... I have to disagree with Dr. Scholz (which I rarely do) in his belief that a G3 always remains a G3. (For this purpose, it makes more sense to speak of the Gleason grade rather than the score.) In the following study, they found that G3 and G4 DNA from adjacent sites had too much DNA in common to have separate origins, but that the G4 had to have originated from that G3, or at least had a common ancestor. In particular, they shared a common genetic impairment called TMPRSS:ERG fusion (which there is a test for):

Clonal progression of prostate cancers from Gleason grade 3 to grade 4.

They start with an important question: why do 70-80% of G3s never progress to higher grade, while the remaining 20-30% do? The answer, from what we've learned so far, is highly complex: genetic variations, switches and mutations, interactions with neighboring cells, endocrine and paracrine effects, and interactions with the environment all play a role.

This study argues for a common ancestor, rather than progression from G3->G4->G5, which supports Scholz' thesis:
The genomic relationship among matched prostate cancer foci.

This study found that true GS6 was never metastatic:
Gleason 6 Prostate Cancers Diagnosed in the PSA Era Are Never Metastatic at the Time of Radical Prostatectomy

but this study found that about 10% of men who died after a diagnosis of CRPC started with GS6... Were they truly GS6 at the time of biopsy, or was there really higher Gleason score cancer that was missed?
Evidence That Gleason Score 6 Cancer Can Evolve to Lethal Disease.

So to answer your first question, what we know so far about the natural history of prostate cancer is true GS6's rarely, if ever, turn into more aggressive disease. Distinguishing true GS6 from those where higher score lesions were missed is part of the job of an AS program -- through biochemical indicators of progression, detectable & growing lesions, and confirmatory biopsies (by saturation or advanced image detection).

To answer your second question about whether a man should be able to choose to have it radically removed anyway... yes -- some men would find it psychologically torture just knowing it's there. I would hope that those men would receive full disclosure of all SEs of treatment, information about what is known of the natural history of PCa, information about the potential benefits and lack of benefits to radical treatment, alternatives to radical treatment, and be given adequate time and perhaps counseling before making such an irrevocable decision. If given all that, he still wants radical treatment and has a willing and able doctor, he should be able to choose it, imho. However, as medved pointed out -- where do we draw the line? Should a man with Gleason 3+2 have this choice? What about Gleason 1+1? Should prophylactic removal of a healthy prostate be allowed based on family history or genetic disposition? All good ethical questions.

- Allen

 

Tall Allen said...

To answer your second question about whether a man should be able to choose to have it radically removed anyway... yes -- some men would find it psychologically torture just knowing it's there. I would hope that those men would receive full disclosure of all SEs of treatment, information about what is known of the natural history of PCa, information about the potential benefits and lack of benefits to radical treatment, alternatives to radical treatment, and be given adequate time and perhaps counseling before making such an irrevocable decision. If given all that, he still wants radical treatment and has a willing and able doctor, he should be able to choose it, imho. However, as medved pointed out -- where do we draw the line? Should a man with Gleason 3+2 have this choice? What about Gleason 1+1? Should prophylactic removal of a healthy prostate be allowed based on family history or genetic disposition? All good ethical questions.

- Allen

One of the ethical dimensions is whether "the public" should be asked to pay for what may then amount to very expensive "elective surgery"...I am speaking in particular about after the name-change removes the psychological "torture" perspective.  Should everyone's insurance premiums, or taxes (for Medicare) be jacked-up to treat someone's unjustifiable fears?

 

 

This hypothetical ethical question may soon be moot...much lower cost deferred focal therapies will likely soon become the new norm for many men at the low-end of the disease spectrum following a period on AS.

Post Edited (Casey59) : 7/29/2013 2:04:55 PM (GMT-6)

PeterD, Not sure the pressure was taken off of me or you with your comment. Actually, I am sure. As I looked into the subject more I knew the word use was improper in its "normal "usage" But I have a thought about, more so, a fascination with words and their usage. I thought my equation was useful, in that it did make sense,to me at least, as pertaining to something after here, a paradoxical synonym, as it were. Not sure I could to that with hereafter relating to some thing before, except of course in the context of when we think of our" past " loves and acquaintances as being in the hereafter. I have actually thought of try to create a game for TV or the parlor in which one takes words and uses them in odd ways not conducive to their normal usage. Ex a verb as a noun, vice a verse. adjective as whatever etc. Take any sentence, rearrange the words in a way that with the " key" the sentence would mean something entirely different. Do I have too much time on my hands? I hope so. BTW, I would that you were less gleeful in your victory.