What should we do with low-risk cancers?
Amid the fears and concerns that the word “cancer” conjures, it is hard to fathom that some cases could be left alone or even undiagnosed. Low-grade, borderline and in situ cancers bear the genetic signatures of malignancies and the corresponding visual hallmarks under a microscope, but they are almost always survivable, even when untreated.
One of the most common examples is ductal carcinoma in situ (DCIS)—a malignancy of the breast characterized by a lack of invasion, meaning that the cells remain in their tissue compartments and don’t invade a layer known as the basement membrane. Therefore these cells do not usually spread or metastasize—essentially the cause of breast cancer fatality. Accordingly, the survival rate of patients who receive a DCIS diagnosis is equivalent to that of unaffected women. As you will read in our feature article, DCIS poses a conundrum, as do other types of lowgrade cancers that have very low mortality rates. Are patients better off never receiving this diagnosis in the first place, sparing them emotional distress as well as the side effects of surgical, radiation and medical treatments? Some have called for new names for low-grade malignancies of the ovaries, skin, blood cells and breast, avoiding words such as “carcinoma.”
Some of these malignancies can be stubborn and continue to progress and evolve into more aggressive cancers even after surgery.
But will a name change alone solve the problem? The sticking point is that some of these malignancies can be stubborn and continue to progress and evolve into more aggressive cancers even after surgery. The term “overtreatment” is being used more often to describe the phenomenon of a population-wide excess of harm from treatment compared with the small number of people helped by more aggressive therapy (for example, lumpectomy, radiation and hormonal therapy for a small DCIS lesion). But the few recurrences make individual decision-making difficult, so we look to technology to help us identify the rare wolf disguised among the flock of sheep to focus treatment on the small number who need it.
Debu Tripathy, MD
Professor of Medicine
Chairman, Department of Breast Medical Oncology
University of Texas MD Anderson Cancer Center