xvi
Introduction
Before addressing the foregoing proposal itself, it is nec-
essary to comment on a matter of semantics relating to the
words “cancer” and “carcinoma” as they were used by the
authors of the aforementioned proposal, as well as many
other authors cited among the references in this book. The
online Merriam Webster Dictionary defines
cancer
as “a
malignant tumor of potentially unlimited growth that ex-
pands locally by invasion and systemically by metastasis.”
Carcinoma
is defined as “a malignant tumor of epithelial
origin.” Thus, carcinoma refers to the subset of malignant
tumors arising from epithelium, whereas cancer refers to
the entire spectrum of malignant tumors, including carci-
nomas, sarcomas, lymphomas, leukemias, and malignant
neoplasms of the central nervous system. Regrettably, Drs.
Esserman, Thompson, and Reid confused these terms
throughout their paper. Although they were mainly con-
cerned with “overtreatment” relating to screening-detected
carcinomas arising at various sites, and pigmented skin le-
sions, they repeatedly used the words
cancer
and
carcinoma
interchangeably. In the second paragraph of the article, they
refer to “breast cancer and prostate cancer” when they ap-
pear to mean carcinoma. The authors’ misuse of these terms
is best appreciated in the following quotation from one of
the summary recommendations: “First, premalignant con-
ditions (eg. ductal carcinoma in situ or high-grade prostatic
intraepithelial neoplasia) should not be labeled as cancers or
neoplasia, nor should the word cancer be in the name.” This
recommendation is meaningless because the word “cancer”
already does not appear in the names of the cited lesions.
It is to be hoped that Drs. Esserman, Thompson, and
Reid are not seeking to deny the concept of
in situ
carci-
noma generally, and in the breast specifically, by referring
to it as a “premalignant” condition. All invasive carcinomas
arise from a preinvasive stage of the disease that develops in
the epithelium from which the carcinoma originates. The
duration of the preinvasive stage is variable, depending on
factors that are largely not known. At the histologic level, the
cytologic appearance of
in situ
carcinoma cells is often indis-
tinguishable from that of the invasive carcinoma it has given
rise to. Molecular studies have shown a high level of concor-
dance in the genetic alterations between these components
in a given tumors that consists of DCIS and invasive ductal
carcinoma, as discussed in Chapters 11 and 12, as well as
Chapters 31 and 32 in the context of lobular carcinoma.
Rather than denying the existence of preinvasive carcinoma,
what is needed is further study to identify the molecular
alterations that endow DCIS (and lobular carcinoma
in situ
[LCIS]) with the ability to invade and metastasize, as well as
changes in the patient’s “resistance” that might enable these
events to occur.
Turning to the flawed proposal, which, if adopted in
its current form, would probably be more harmful than
beneficial, it is self-evident that changing the name of a
disease would not change the disease itself. Despite some
general principles that invasive carcinomas appear to have
in common, such as epithelial origin and a preinvasive,
induce carcinomas at a later date, but this proved to be of
less concern because in subsequent years, advances in mam-
mography technology led to substantially reduced radiation
exposure. Many later studies documented the feasibility of
mammography screening and also confirmed that it reduced
breast carcinoma deaths in the screened populations.
25–30
Encouraged by the success of breast screening and with
the availability of suitable tests, screening for the detection
of occult tumors in other organs such as the prostate gland
and lungs was introduced, again prompting criticisms of
“overdiagnosis” and “overtreatment.”
31,32
In this regard, a
study that reported a reduction in deaths due to carcinoma
of the lung after screening with low-dose CT scans also
noted that 96.4% of “positive” screening findings did not
prove to be carcinoma, resulting in a large number of diag-
nostic procedures that did not benefit these individuals.
33
In March 2012, the NCI sponsored a meeting to once
again address concerns that screening results in the “over-
diagnosis” of cancer. A report summarizing the conclusions
of the participants was published in July, 2013
34
in an article
that attracted wide public attention. The authors of the re-
port defined “overdiagnosis” as a diagnosis “…which occurs
when tumors are detected that, if left unattended, would not
become clinically apparent or cause death. Overdiagnosis,
if not recognized, generally leads to overtreatment.” It was
concluded that “overdiagnosis” most often occurs as a re-
sult of screening when clinically asymptomatic, “indolent”
cancers are likely to be detected. In this context, the authors
defined “cancer” as a disease “…with a
reasonable
(my
Italics) likelihood of lethal progression if left untreated.” The
word “reasonable” was not defined by the authors, but pre-
sumably referred to an unspecified risk that a patient would
experience a fatal outcome.
The authors also recommended that the word “cancer”
should be dropped from what were referred to as “premalig-
nant conditions” such as DCIS that should be renamed “in-
dolent lesions of epithelial origin” under the acronym IDLE
conditions. They suggested that this change would remove
the frightening connotation associated with “cancer” and re-
duce “overtreatment” by making it easier to recommend less
aggressive therapy for “indolent” lesions. In support of this
position, it was argued that not all
in situ
carcinomas in vari-
ous organs progress to an invasive stage if left untreated, as
evidenced by the clinical biology of prostatic (PIN) and cer-
vical (CIN) neoplasia, and that in some instances (e.g., the
prostate gland) the invasive neoplasms that ultimately arise
are so indolent that they pose little danger in the lifetime of
the patient. A corollary of latter argument was that the cur-
rent tendency to manage all
in situ
carcinomas with equally
aggressive treatments results in the overtreatment of some
patients who might not have needed the recommended
therapy, and may have been harmed by it. Finally, being able
to replace costly treatment with observation would reduce
healthcare costs. In summary, it was suggested that simply
changing the name of a disease would result in important
improvements in patient well-being and save money.
