Should we rename low risk cancers?
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k4699 (Published 23 January 2019) Cite this as: BMJ 2019;364:k4699
- Laura J Esserman, director1,
- Murali Varma, consultant histopathologist2
- 1UCSF Carol Franc Buck Breast Care Center, San Francisco, CA, USA
- 2Department of Cellular Pathology, University Hospital of Wales, Cardiff, UK
- Correspondence to: L J Esserman laura.esserman{at}ucsf.edu, M Varma wptmv{at}cf.ac.uk
Yes—Laura J Esserman
No medical diagnosis evokes such universal fear as one with the word “cancer.” It is a compelling argument that ethics alone require us to use a strict definition of the word to avoid unnecessary harm to our patients—psychological, physical, and financial—from unnecessarily invasive investigation and treatment.1
The clinical definition of cancer describes a disease that, if untreated, will grow relentlessly and spread to other organs, killing the host. What we routinely refer to as cancer today is a disease marked by heterogeneity, varying in metastatic potential from ultralow (<5% chance of progression over two decades) to extremely high (>75% chance of progression over one to two years). Many thyroid, prostate, and breast cancers are ultralow risk lesions.
Ultralow risk
Today, a “breast cancer” diagnosis encompasses a range of conditions, from tumours with high risk of early recurrence, which are most likely to need cytotoxic and biological therapies; through those with risk of late recurrence, which is best mitigated with hormonal therapy; to those with ultralow risk and for which breast cancer specific survival of 10 years (even without systemic therapy) is 100%.2 Clearly, a condition that is indolent or rarely metastasises is not a cancer as clinically defined.
Diagnosis requires the same microscopic interpretation that has been in place for decades. In the past, it was not possible to reliably identify lesions with negligible risk. Today, genomic tests inform our understanding of the risk and timing of recurrence, but we have yet to use them to change how we define cancer. Molecular classifications and other hallmarks of ultralow risk lesions are being investigated.1
The increased incidence of …
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