Gastroenterology Press Highlights

Archives | AGA | August 5, 2013

NCI Panel Warns of Overdiagnosis of

Story by: Kristine Novak, PhD, Science Editor, AGA Journals Reviewed by Press Highlights Section Editor: Grace L. Su, MD, University of Michigan Medical School

The practice of in the United States requires reforms and initiatives to reduce the overdiagnosis and overtreatment of cancer, according to a working group of the National Cancer Institute.

The group says that a number of premalignant conditions, including ductal carcinoma in situ and high-grade prostatic intraepithelial neoplasia, should no longer be called cancer.

Instead, the conditions should be labeled more appropriately, such as indolent lesions of epithelial origin (IDLE), the group proposed in a report was published online July 29 in JAMA.

The term cancer “should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated," wrote the 3 members of the working group (Laura Esserman from the University of California at San Francisco, Ian Thompson from the University of Texas Health Science Center at San Antonio, and Brian Reid from the Fred Hutchinson Cancer Research Center in Seattle).

According to Medscape Medical News, the report proposes a multidisciplinary effort of the pathology, imaging, surgical, advocate, and medical communities, convened by an independent group (such as the Institute of ) “to revise the taxonomy of lesions now called cancer and to create reclassification criteria for IDLE conditions."

The report states that changes are needed because programs designed to reduce the rate of late- stage disease and cancer mortality have not met their goals. However the committee noted that early detection and removal of precancerous colon and cervical lesions has reduced the incidence of those .

According to the New York Times, the development of highly sensitive screening technologies has increased the likelihood of finding incidental lesions that might never cause problems. However, once doctors and patients are aware of the lesion, they feel compelled to “biopsy, treat, or remove it, resulting in subjection of patients to unnecessary procedures or overtreatment.” Esserman explained to The Washington Post that not every finding must result in action. “More is not always better,” she said. “It’s pretty clear that cancer — the word now refers to a wide range of conditions, some of which will not progress and will not kill you…. We have to be a little bit more savvy.”

Otis Brawley, chief medical officer of the , told The Washington Post that a diagnosis that contains the word ‘cancer’ often causes so much anxiety for the patient and pressure on a physician to act that many women unnecessarily undergo radiation treatment or mastectomies.

In addition to changes in cancer terminology, the NCI working group proposes other changes to reduce overdiagnosis of cancer and overtreatment of early-stage lesions. First, "physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with cancer screening," says the report. The group proposes creating observational registries for lesions with low malignant potential, to improve information about related disease progression, which would help in the uptake of "alternative treatment strategies, such as active surveillance,"

The New York Times article cites the Barrett’s Esophagus Translational Research Network (BETRnet) as an example of the NCI’s effort to learn more about which lesions are most likely to become cancer, so that patients can be managed appropriately, based on risk. BETRnet researchers from various academic centers are analyzing tissue samples to determine when Barrett’s is most likely to become cancerous.

The NCI working group report also presents strategies to decrease detection of indolent disease, such as reducing low-yield diagnostic evaluations and the frequency of screening examinations. They propose focusing screening on high-risk populations, and raising thresholds for recall and biopsy.

Finally, the report proposes alternatives to surgical excision by controlling the environment in which precancerous and cancerous conditions arise. “Changes to diet or chemoprevention can be as effective and less toxic than more traditional therapies in lower-risk tumors," Thompson explained to Medscape Medical News.

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