Overdiagnosis & Overtreatment of Cancer Leads to New Terminology

Submitted by melkonya on Fri, 01/13/2017 - 12:06
Dr. Virginia A. LiVolsi

In 2012, a group of distinguished scientists convened at the National Cancer Institute (NCI) to discuss the problem of over diagnosis and hence overtreatment of cancer. This group published in 2014, the article entitled "Addressing over diagnosis and overtreatment in cancer" (Read the abstract Pub Med Reference (PMC4322920)). The group pointed out appropriately that cancer describes a wide range of diseases from indolent to fast growing lesions. They proposed a new terminology for indolent and precancerous disorders such as "indolent lesion of epithelial origin or IDLE”.

Among lesions they suggested would be overtreated low grade and intraductal breast lesions, low grade prostatic neoplasms and encapsulated thyroid neoplasms. The removal of the word "cancer" or "carcinoma" from the diagnosis of such lesions, which by their very nature haven't indolent clinical behavior and if left untreated might never manifest clinically, would relieve patient and family stress, save large amounts of medical care dollars and unclog doctors' offices, radiology facilities and pathology laboratories.

One such approach has been the study of outcomes of encapsulated or completely circumscribed follicular patterned lesions of the thyroid gland. A study encompassing 210 follicular thyroid tumors, half of which were totally noninvasive and half which showed capsular and/or vascular invasion has been published. A group of 23 international recognized endocrine pathologists joined by endocrine surgeons and endocrinologists, identified the fact that those lesions that were noninvasive showed no recurrence or metastasis after 14 years of median follow-up. All of these tumors had been treated by surgery alone without postoperative adjuvant therapy. (Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma. JAMA Oncol. 2016;2(8):1023-1029. doi:10.1001/jamaoncol.2016.0386). The group of tumors with invasion however, after only a 5 year follow-up showed a 12% adverse outcome including 2% mortality from tumor.

Hence, this study identified a group of thyroid neoplasms which when carefully characterized pathologically are associated with extremely low aggressive clinical behavior. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is the new term proposed to identify these neoplasms. A publication defining these lesions by inclusion and exclusion criteria from a histopathologic viewpoint awaits further confirmation by larger studies. Should these findings hold up, this would be the first example to apply the principles espoused by the NCI committee; further studies on other cancers of different organ systems with careful pathologic definitions and adequate follow-up would hopefully result in the goal a reasonable approach to therapy, decreased patient stress, and decreased medical care costs.

Read the New York Times article describing the above study  https://www.nytimes.com/2016/04/15/health/thyroid-tumor-cancer-reclassification.html?_r=0 

About the Author: Dr. Virginia A. LiVolsi, MD is world renowned pathologist, Professor of Pathology & Laboratory Medicine, Professor of Otorhinolaryngology Head & Neck Surgery, as well as the Director of Strategic Initiatives and Quality Improvement (Anatomic Pathology) at the University of Pennsylvania Perelman School of Medicine.